SAMPLE UNCLAIMED PROPERTY FORM 
Account 
No.
Last 
Name
First 
Name
Middle 
name
IN Trust 
For
AND/OR
Last Trans.
Street / PO Box
City
State
Zip 
code
Amount 
Balance
Unclaimed 
Balance
Amt. 
Reported  
Claimed/ 
Reactivated
 
Date Account 
Claimed/ 
Reactivated
 
 
67485
Doe
John
P
 
Sue Mark
08/29/2007
P.O. Box 111
Christiansted
V I
00820
$294.00
$294.00