THE UNITED STATES VIRGIN ISLANDS
THE UNITED STATES VIRGIN ISLANDS
THE UNITED STATES VIRGIN ISLANDS
THE UNITED STATES VIRGIN ISLANDS 
OFFICE OF THE LIEUTENANT GOVERNOR 
DIVISION OF BANKING AND INSURANCE 
 
GREGORY R. FRANCIS
GREGORY R. FRANCIS
GREGORY R. FRANCIS
GREGORY R. FRANCIS 
 
 
 
 
 
 
 
COMMISSIONER OF INSURANCE
COMMISSIONER OF INSURANCE
COMMISSIONER OF INSURANCE
COMMISSIONER OF INSURANCE 
LIEUTENANT GOVERNOR
LIEUTENANT GOVERNOR
LIEUTENANT GOVERNOR
LIEUTENANT GOVERNOR 
 
 
 
 
 
 
  
CHAIRMAN, V.I. BANKING BOARD
CHAIRMAN, V.I. BANKING BOARD
CHAIRMAN, V.I. BANKING BOARD
CHAIRMAN, V.I. BANKING BOARD 
 
 
REPORT OF PROPERTY SUBJECT TO THE UNIFORM UNCLAIMED PROPERTY ACT FOR THE YEAR 
ENDED___________________________________________ 
                                                       (For Life Insurance Companies- May 1st -- For all others- November 1st ) 
 
 
Name of Holder: _____________________________________              Year in which you qualified to do business 
V.I. ______________ 
Mailing Address: ______________________________________ 
City, County, State and Zip Code: _________________________  
Date _____________________ 
□  Zero/Negative filing (If checked, complete holder and  contact person information and Affidavit) 
In compliance with Title 28, Chapter 29, Virgin Islands Code the “Uniform Unclaimed Property Act” the 
above holder hereby reports the following unclaimed property subject to the Act.  
All moneys held and owing by any holder thereof doing business in this 
Territory which shall have remained unclaimed and unpaid and presumed 
abandoned as provided in the above Act, as reported in detail on the 
attached_________ sheets, and amounting in total to  . . . . . . 
$___________________ 
 
All stocks or other certificates of ownership, and all other property, not in 
the form of money, held or owing, as defined in the Act, and as reported in 
detail on the attached__________ sheets, the estimated value which is   
$________________. 
 
If you are a successor to a previous holder of the property reported above, or if you have changed your name, 
please list such prior name(s) below, and show the year in which the change became effective. 
 
Name____________________________Address_____________________________Year_____________ 
 
Name____________________________Address_____________________________Year_____________ 
 
(If more space is needed, continue this list on the reverse side) 
 
PLEASE LIST CONTACT PERSON  
NAME AND PHONE NUMBER 
__________________________________ 
 
__________________________________ 
 
AFFIDAVIT 
 
 
Territory of _____________________________ 
 
District of ______________________________ 
 
I,______________________________________ _____________________________ of the company, or  
     
(Type in name of officer, owner, etc.) 
 
 
(Type in title of person signing) 
 
holder, for which this report is made, being duly sworn (or affirmed) according to the law do depose and say that this report 
is true and contains all facts required by law to be reported. 
 
 
Sworn to (or affirmed) and subscribed before me this 
 
 
________  day of____________________, 20______ ___ 
____________________________________ 
 
 
 
 
 
 
 
 
 
(Signature of officer, owner, etc.) 
 
___________________________________________ 
 
 
                 (Notary Public) 
 
 
My commission expires on_______________________ 
____________________________________ 
 
 
 
 
 
 
 
 
 
(Title of person signing)