Fillable REPORT OF PROPERTY WHICH MAY BE SUBJECT TO (State of Tennessee)

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REPORT OF PROPERTY WHICH MAY BE SUBJECT TO (State of Tennessee)

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STATE OF TENNESSEEwTREASURY DEPARTMENT
Unclaimed Property Division
P.O. Box 198649wNashville, Tennessee 37219-8649w(615) 253-5362
www.tn.gov/treasury/unclaim
REPORT OF PROPERTY WHICH MAY BE SUBJECT TO ESCHEAT
This report is to be filed in accordance with T. C. A. § 31-6-101 et seq. (See next page)
Part I - Give FULL Information on Decedent _________________________
Date of Death
Name
____________________________________________________________________________________________________
Last First Middle Maiden
Address
____________________________________________________________________________________________________
Street City State Zip Code County
Part II - List ALL Property Belonging to Decedent at Death
Description Location (including county) Approximate Value
1. ______________________________ _________________________________
______________________________ _________________________________ $ _____________________
2. ______________________________ _________________________________
______________________________ _________________________________ $ _____________________
3. ______________________________ _________________________________
______________________________ _________________________________ $ _____________________
4. ______________________________ _________________________________
______________________________ _________________________________ $ _____________________
5. ______________________________ _________________________________
______________________________ _________________________________ $ _____________________
Attach additional schedule if necessary.
Reason for believing property is subject to Escheat: (Attach all court filings and forward any future filings.)
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Possible Claimants to Property: (If to specific item of property, please indicate.)
Name Social Security No. Address Phone Number
____________________ __________________ _______________________ ________________
____________________ __________________ _______________________ ________________
Report filed by: _________________________________________________________________________
Relationship to decedent: _________________________________________________________________
Address: ______________________________________________________________________________
Street City State Zip Code
Phone Number: ________________________ E-Mail Address: __________________________
(Continued on next page)
TR 0223 Rev. 10/01 RDA 2128
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Part III - Verification
The undersigned declares, under penalty of perjury, that, to the best of (his) (her) knowledge, this report
contains a full, true and complete listing of property belonging to _____________________________, which
may be subject to escheat in accordance with Tennessee Code Annotated, Section 31-6-101 et seq.
Date _________________________________ Signature ________________________________
State of ______________________________
City/County ___________________________
Subscribed and sworn to before me this _______ day of _________________________ 20_____
Notary Public __________________________
My Commission Expires _________________ Seal
This report is to be filed in accordance with Tennessee Code Annotated, Section 31-6-107(a), which states:
(a) All administrators, executors, trustees, guardians, or other fiduciaries having in their custody or
control property which may be subject to escheat pursuant to this chapter shall promptly, after
obtaining knowledge as to facts indicating the possibility of the escheat of any such property, file with
the state treasurer a report on such forms as he may prescribe, showing, with such other information
as the treasurer may require, the nature, location and approximate value of such property, the basis
for believing that it may be subject to escheat, and whether there are any other persons who have
asserted or may assert claims thereto.
This report should be filed with: Tennessee Treasury Department
Unclaimed Property Division
P.O. Box 198649
Nashville, TN 37219-8649
Contact
Phone: 615-253-5362
E-Mail: UCP.holders@state.tn.us
TR 0223 RDA 2128
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REPORT OF PROPERTY WHICH MAY BE SUBJECT TO (State of Tennessee)

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Completed 20 July 2020

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