This questionnaire is designed to identify areas of your activities that may be at-risk for the occurrence of unclaimed property. An accurate and complete response will assist in assessing whether a potential unclaimed property liability exists and avoid further enforcement action. Please answer all questions on both pages of this form that are relevant to your operation within 30 days. If a question does not apply, please respond by noting 'N/A' (not applicable). The scope of this self audit review should include records for the last ten years (i.e., 2003 through 2012).

* 1. Please enter company name & holder number:

* 2. State of Incorporation & email address

* 3. Year of Incorporation

* 4. Is there a formalized policy in place to address Unclaimed Property?