THE UNITED STATES VIRGIN ISLANDS
THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE 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. …
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THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE 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) OFFICE OF THE COMMISSIONER Kongens Gade No. 5049 DIVISION OF BANKING AND INSURANCE Charlotte Amalie St. Thomas, Virgin Islands, 00802 (340)774-7166 ANNUAL REPORT OF PROPERTY PRESUMED ABANDONED (Detail Sheet) Name of Holder Date Identifying Number Name of Owner (Listing names alphabetically by surname) Last Known Adresss Date Due or Returnable Date of Last Transaction Amount or Value TOTAL AMOUNT OF THIS PAGE → → $