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Form Number 496-UP -Revision 06/11/2013

OKLAHOMA STATE TREASURER UNCLAIMED PROPERTY DIVISION

REPORT OF UNCLAIMED PROPERT – VERIFICATION AND CHECKLIST

Verification for Period Ended _______________, ______

Provide the name of the holder company reporting for the period indicated. List the prior name(s), FEI(s), or address(es) if the company has had a change in these items during the time period in which it has held the property being reported.

Name ________________________________________________________	State of Incorporation______________________________________
_____________________________________________________________	Date of Incorporation _______________________________________
Address ______________________________________________________	Federal Employer ID#_______________________________________
_____________________________________________________________

Every person, corporation, or other business association, banking or financial organization, life insurance corporation, utility, court or public authority must complete the following checklist before filing their Oklahoma Unclaimed Property Report. This checklist includes by way of illustration, but not limitation, those items which are covered by Sections of the Oklahoma Unclaimed Property Law.

Please complete the checklist by indicating the items being reported. A “Yes” must be enumerated on Unclaimed Property Form 497-UP-2. Property Type Codes and Abandonment Periods

					Account Balances Due
Yes	No	Code Description		Yr	Yes	No	Code	Description	Yr
___	___	AC01	Checking Accounts	5	___	___	AC06	Security Deposits	5
___	___	AC02	Savings Accounts	5	___	___	AC07	Unidentified Deposits	5
___	___	AC03	Matured CD or Saving Certificate	5	___	___	AC08	Suspense Accounts	5
___	___	AC04	Christmas Club Funds	5	___	___	AC99	Aggregate Account Balances	5
___	___	AC05	Money on Deposit to Secure Fund	5

					Court Deposits
___	___	CT01	Escrow Funds	1	___	___	CT04	Suspense Accounts	1
___	___	CT02	Condemnation Awards	1	___	___	CT05	Other Court Deposits	1
___	___	CT03	Missing Heirs’ Funds	1	___	___	CT99	Aggregate Court Deposits	1

					Health Savings Plan
___	___	HS01	Health Savings Account	5	___	___	HS02	Suspense Accounts	5
					Insurance
___	___	IN01 Individual Policy Benefits or Claim Payments		5	___	___	IN06	Unidentified Remittances	5
___	___	IN02 Group Policy Benefits or Claim Payment		5	___	___	IN07	Other Amounts Due Under Policy Terms	5
___	___	IN03 Proceeds Due Beneficiaries		5	___	___	IN08	Agent Credit Balances	5
___	___	IN04 Proceeds from Matured Policies,		5	___	___	IN09	Proceeds from Demutualization	2
			Endowments, or Annuities		___	___	IN10	Shares of Stock from Demutualization	2
___	___	IN05 Premium Refunds		5	___	___	IN99	Aggregate Insurance Property	5
				IRA’S (TRADITIONAL/ROTH)
___	___	IR01 Traditional IRA – Cash		7**	___	___	IR05	Roth IRA – Cash	7**
___	___	IR02 Traditional IRA – Mutual Fund		7**	___	___	IR06	Roth IRA– Mutual Funds	7**
___	___	IR03 Traditional IRA – Securities		7**	___	___	IR07	Roth IRA– Securities	7**
** IRA’s are reportable 7 years after the participant has attained the age of 70 1/2.
				Mineral Proceeds and Mineral Interests
___	___	MI01	Net Revenue Interest	5	___	___	MI06	Bonuses	5
___	___	MI02	Royalties	5	___	___	MI07	Delay Rentals	5
___	___	MI03	Overriding Royalties	5	___	___	MI08	Shut‐In Royalties	5
___	___	MI04	Production Payments		___	___	MI09	Minimum Royalties	5
___	___	MI05	Working Interest	5
			Miscellaneous Checks and Intangible Personal Property
___	___	MS01	Wages, Payroll, and Salary	1	___	___	MS11	Refunds Due	5
___	___	MS02	Commissions	5	___	___	MS12	Unredeemed Gift Certificates	5
___	___	MS03	Worker’s Compensation Benefits	5	___	___	MS13	Unclaimed Loan Collateral	5
___	___	MS04	Payment for Goods and Services	5	___	___	MS14	Pension & Profit Sharing Plans	7**
___	___	MS05	Customer Overpayments	5	___	___	MS15	Dissolution or Liquidation	1
___	___	MS06	Unidentified Remittances	5	___	___	MS16	Misc Outstanding Checks	5
___	___	MS07	Un‐refunded Overcharges	5	___	___	MS17	Misc Intangible	5
___	___	MS08	Accounts Payable	5	___	___	MS18	Suspense Liabilities	5
___	___	MS09	Credit Balance ‐ Accounts Receivable	5	___	___	MS99	Aggregate Misc Property	5
___	___	MS10	Discounts Due	5
				Safe Deposit Boxes and Safekeeping
___	___	SD01	Safe Deposit Box Contents	5	___	___	SD03	Other Tangible Property	5
___	___	SD02	Other Safekeeping	5

					Securities
Yes	No	Code	Description	Yr	Yes	No	Code	Description	Yr
___	___	SC01	Dividends	3	___	___	SC13	Funds for Liquidation/Redemption	3
___	___	SC02	Interest (Bond Coupons)	3				of Un‐surrendered Stocks or Bonds
___	___	SC03	Principal Payments	3	___	___	SC14	Debentures	3
___	___	SC04	Equity Payments	3	___	___	SC15	US Government Securities	5
___	___	SC05	Profits	3	___	___	SC16	Mutual Fund Shares	3
___	___	SC06	Funds Paid to Purchase Shares	3	___	___	SC17	Warrants (Rights)	3
___	___	SC07	Funds for Stocks and Bonds	3	___	___	SC18	Matured Bond Principal	3
___	___	SC08	Shares of Stock Returned by Post Office	3	___	___	SC19	Dividend Reinvestment Plans	3
___	___	SC09	Cash for Fractional Shares	3	___	___	SC20	Credit Balances	3
___	___	SC10	Un‐exchanged Stock of Successor Corp	3	___	___	SC21	Common Stock	3
___	___	SC11	Other Certificates of Ownership	3	___	___	SC22	Convertible Securities	3
___	___	SC12	Underlying Shares or Other	3	___	___	SC23	Preferred Securities	3
			Outstanding Certificates		___	___	SC24	Fixed Income Securities	3
					___	___	SC25	Real Estate‐Based Securities	3
				Trust, Investment, and Escrow Accounts
___	___	TR01	Paying Agent Accounts	5	___	___	TR04	Escrow Accounts	5
___	___	TR02	Undelivered or Uncashed Dividends	5	___	___	TR05	Trust Vouchers	5
___	___	TR03	Funds Held in Fiduciary Capacity	7	___	___	TR99	Aggregate Trust Property	5
					Uncashed Checks
___	___	CK01	Cashier’s Checks	5	___	___	CK10	Expense Checks	5
___	___	CK02	Certified Checks	5	___	___	CK11	Pension Checks	5
___	___	CK03	Registered Checks	5	___	___	CK12	Credit Checks or Memos	5
___	___	CK04	Treasurer’s Checks	5	___	___	CK13	Vendor Checks	5
___	___	CK05	Drafts	5	___	___	CK14	Checks Written Off to Income	5
___	___	CK06	Warrants	5	___	___	CK15	Other Outstanding Official Checks	5
___	___	CK07	Money Orders	7	___	___	CK16	CD Interest Checks	5
___	___	CK08	Traveler’s Checks	15	___	___	CK99	Aggregate Uncashed Checks	5
___	___	CK09	Foreign Exchange Checks	5
					Utilities
___	___	UT01	Utility Deposits	1	___	___	UT04	Capital Credit Distribution	5
___	___	UT02	Membership Fees	1	___	___	UT99	Aggregate Utility Property	1
___	___	UT03	Refunds or Rebates	1

Please indicate the primary business activity of your company ________________________________________________________________________

Did you file a report of unclaimed property last year: YES ______ NO ______ If no, please explain: _______________________________________

Holder Contact: ___________________________________________________________________ Telephone Number: ________________________

Claim Person: ___________________________________________________________________ Telephone Number: ________________________

Address:__________________________________________________________________________________________________________________

State of ___________________________________________________:

County of _________________________________________________: SS

I, _________________________________________________________________, being first duly sworn, on oath depose and state that I have caused to be prepared

and have examined this report consisting of ________ pages totaling $ ____________, ______________ shares, and ____________ safekeeping items as to property

presumed abandoned under the Oklahoma Unclaimed Property Law for the year ending as stated, that I am duly authorized to execute this verification by the holder and by law and that I believe that said report is true, correct and complete as of said date, excepting for such property as has since ceased to be abandoned.

Signature ________________________________________________________________ Title _________________________________________________

Subscribed and sworn to before this _______________ day of ___________________________, _________________.

Notary Signature: _________________________________________________________________________________

My Commission Expires the __________________ day of _____________________________, _________________.

Mail reports and make checks payable to:

Oklahoma State Treasurer

Unclaimed Property Division

2300 N Lincoln Blvd., Rm. 217

Oklahoma City, Oklahoma 73105‐4895

Reporting: (405) 521‐4275

Question	Answer
Form Name	Oklahoma Unclaimed Property Form 496 Up
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	form 496 up, oklahoma unclaimed property form 496 up, oklahoma form 496 up, oklahoma stae treasurer unclaimed property for 496 up

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