ASD-21 - North Carolina State Treasurer

HOLDER NAME
HOLDER ID# (IF KNOWN)
FEDERAL IDENTIFICATION NUMBER
CLASS CODE
ACCOUNT NUMBER
OWNER 1 NAME (LAST, FIRST, MI)
-----
CHECK NUMBER
SSN/FEIN
OWNER 1 ADDRESS (STREET, CITY, STATE, ZIP)
OWNER 2 NAME (LAST, FIRST, MI)
TYPE
CLASS CODE
ACCOUNT NUMBER
OWNER 1 NAME (LAST, FIRST, MI)
SSN/FEIN
OWNER 2 ADDRESS (STREET, CITY, STATE, ZIP)
STATUTORY
REDUCTIONS
TYPE
DATE OF BIRTH
DRIVERS LICENSE # STATE
AMOUNT
LAST TRANSACTION DATE
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
COMMENTS
CHECK NUMBER
OWNER 1 ADDRESS (STREET, CITY, STATE, ZIP)
OWNER 2 NAME (LAST, FIRST, MI)
DRIVERS LICENSE # STATE
AMOUNT
SSN/FEIN
$ AMOUNT REMITTED
DATE OF BIRTH
SSN/FEIN
OWNER 2 ADDRESS (STREET, CITY, STATE, ZIP)
STATUTORY
REDUCTIONS
PAGE(S)
$ AMOUNT REMITTED
DATE OF BIRTH
DRIVERS LICENSE # STATE
DATE OF BIRTH
DRIVERS LICENSE # STATE
LAST TRANSACTION DATE
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
COMMENTS
Total this Page:
Report Total:
If this is the last page of report, enter total to be remitted and carry over to ASD-159.
REV 07/2015
ASD-21
CLASS CODE
ACCOUNT NUMBER
OWNER 1 NAME (LAST, FIRST, MI)
CHECK NUMBER
SSN/FEIN
OWNER 1 ADDRESS (STREET, CITY, STATE, ZIP)
OWNER 2 NAME (LAST, FIRST, MI)
STATUTORY
REDUCTIONS
TYPE
CLASS CODE
ACCOUNT NUMBER
OWNER 1 NAME (LAST, FIRST, MI)
TYPE
CLASS CODE
ACCOUNT NUMBER
OWNER 1 NAME (LAST, FIRST, MI)
TYPE
DRIVERS LICENSE # STATE
DATE OF BIRTH
DRIVERS LICENSE # STATE
AMOUNT
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
LAST TRANSACTION DATE
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
COMMENTS
CHECK NUMBER
SSN/FEIN
$ AMOUNT REMITTED
DATE OF BIRTH
AMOUNT
SSN/FEIN
LAST TRANSACTION DATE
COMMENTS
SSN/FEIN
OWNER 2 ADDRESS (STREET, CITY, STATE, ZIP)
STATUTORY
REDUCTIONS
DRIVERS LICENSE # STATE
SSN/FEIN
OWNER 1 ADDRESS (STREET, CITY, STATE, ZIP)
OWNER 2 NAME (LAST, FIRST, MI)
DATE OF BIRTH
CHECK NUMBER
OWNER 2 ADDRESS (STREET, CITY, STATE, ZIP)
STATUTORY
REDUCTIONS
DRIVERS LICENSE # STATE
AMOUNT
OWNER 1 ADDRESS (STREET, CITY, STATE, ZIP)
OWNER 2 NAME (LAST, FIRST, MI)
DATE OF BIRTH
SSN/FEIN
OWNER 2 ADDRESS (STREET, CITY, STATE, ZIP)
$ AMOUNT REMITTED
$ AMOUNT REMITTED
DATE OF BIRTH
DRIVERS LICENSE # STATE
DATE OF BIRTH
DRIVERS LICENSE # STATE
LAST TRANSACTION DATE
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
COMMENTS
Total this Page:
Report Total:
If this is the last page of report, enter total to be remitted and carry over to ASD-159.
REV 07/2015
ASD-21
CLASS CODE
ACCOUNT NUMBER
OWNER 1 NAME (LAST, FIRST, MI)
CHECK NUMBER
SSN/FEIN
OWNER 1 ADDRESS (STREET, CITY, STATE, ZIP)
OWNER 2 NAME (LAST, FIRST, MI)
STATUTORY
REDUCTIONS
TYPE
CLASS CODE
ACCOUNT NUMBER
OWNER 1 NAME (LAST, FIRST, MI)
TYPE
CLASS CODE
ACCOUNT NUMBER
OWNER 1 NAME (LAST, FIRST, MI)
TYPE
DRIVERS LICENSE # STATE
DATE OF BIRTH
DRIVERS LICENSE # STATE
AMOUNT
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
LAST TRANSACTION DATE
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
COMMENTS
CHECK NUMBER
SSN/FEIN
$ AMOUNT REMITTED
DATE OF BIRTH
AMOUNT
SSN/FEIN
LAST TRANSACTION DATE
COMMENTS
SSN/FEIN
OWNER 2 ADDRESS (STREET, CITY, STATE, ZIP)
STATUTORY
REDUCTIONS
DRIVERS LICENSE # STATE
SSN/FEIN
OWNER 1 ADDRESS (STREET, CITY, STATE, ZIP)
OWNER 2 NAME (LAST, FIRST, MI)
DATE OF BIRTH
CHECK NUMBER
OWNER 2 ADDRESS (STREET, CITY, STATE, ZIP)
STATUTORY
REDUCTIONS
DRIVERS LICENSE # STATE
AMOUNT
OWNER 1 ADDRESS (STREET, CITY, STATE, ZIP)
OWNER 2 NAME (LAST, FIRST, MI)
DATE OF BIRTH
SSN/FEIN
OWNER 2 ADDRESS (STREET, CITY, STATE, ZIP)
$ AMOUNT REMITTED
$ AMOUNT REMITTED
DATE OF BIRTH
DRIVERS LICENSE # STATE
DATE OF BIRTH
DRIVERS LICENSE # STATE
LAST TRANSACTION DATE
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
OWNER RELATIONSHIP CODE
EMAIL ADDRESS
COMMENTS
Total this Page:
Report Total:
If this is the last page of report, enter total to be remitted and carry over to ASD-159.
REV 07/2015
ASD-21
INSTRUCTIONS FOR COMPLETING THE ASD-21
(A completed ASD-21 must be accompanied with a completed and signed ASD-159 to be accepted.)
NOTE - This form should only be used when reporting less than 50 owners. If 50 or more, holders are required to report
electronically in the file format prescribed by the Treasurer. Free electronic reporting software is available at
www.nccash.com/reporting.
Holder ID # - Number listed above company name on the mailing label. If number is unknown, please leave blank.
Class Code – Classification of the type of property being reported. Refer to ‘Class Codes and Dormancy Period Chart’.
$ Amount Remitted – Net amount remitted after any Statutory Reduction.
Owner Relationship Codes
AD - Administrator
AF - Attorney For
AG - Agent For
AN - And
BF - Beneficiary
CF - Custodian For
CN - Conservator
CP - Community Property
DB - Doing Business As
DF - Defendant
EX - Executor or Executrix
ES - Estate
FB - For Benefit of
GR - Guardian
HE - Heir
IN - Insured
JE - Tenants in Entireties
JS - Joint Tenants with Rights
of Survivorship
JT - Joint Tenants
OR – (Or) Unspecified Joint
Relationship
OT - Other Relationship
PA - Payee
PD - Payable on Death
PO - Power of Attorney
RE - Remitter
SO - Sole Owner
TC - Tenants in Common
TE - Trustee
UF - Usufruct
UG - Uniform Gifts to Minor
UN - Unknown
UT - Uniform Transfer to Minor
Visit www.nccash.com/reporting and click "Forms and Guides" for the full Owner Relationship Codes with definitions.
Drivers License # State – List drivers license number, if known, and the State of issuance for each owner.
Statutory Reduction – List the type of statutory reduction (‘D’ or ‘O’) and the amount of the reduction. Please attach a
sample contract and/or statute which authorize the reduction taken.
D = Dormancy Charge-116B-57(a). A reasonable charge imposed by reason of the owner’s failure to claim
the property within a specified time and only if there is a valid and enforceable written contract under which the
holder may impose the charge.
O = Other-116B-57(b). Lawful charges specifically authorized by statute or by valid and enforceable contract.
Holders must make a good faith effort to locate owners. If the holder imposes these charges, they must be
imposed on all owners and not regularly reversed or canceled for some owners and not others, except in case of
bona fide errors in imposing the charges.
Postage is not a valid reduction unless specified in a written contract.
Aggregate Items –Any amounts under $50.00 may be “lumped together” and reported as ‘Aggregate’ without listing the
individual owner’s name and address. To assist in refunds, you may enclose a detail listing of aggregate amounts for our
files. Aggregate amounts should be summed by property code groups and listed in the “last” name field as ‘Aggregate’.
Multiple aggregate amounts may be listed on the form. Exception – Aggregates properties pertaining to intangible
earnings and capital gains (i.e. dividends) from securities and mutual funds should be listed by owner name, regardless of
the amount of unclaimed property being reported.
Late Interest – In addition to any other penalties, any business, government or organization holder filing after November 1
(May 1 for life insurance holder) shall remit interest at the rate pursuant to North Carolina General Statute 116B-77,
currently 5%. Interest penalty is computed as follows: Total amount of property reportable X # of days late/365 X 5%=
interest penalty.
Securities – All unclaimed securities (stocks, bonds, and mutual funds) must be reported on Form ASD-215.
Tangible Property – All unclaimed tangible property (safe deposit contents and cash held in safekeeping) must be
reported on Form ASD-127.
MAIL REPORTING FORMS AND REMITTANCE TO:
North Carolina Department of State Treasurer
Unclaimed Property Division
3200 Atlantic Avenue
Raleigh, NC 27604-1668
Telephone: (919) 814-4200
REV 07/2015
ASD-21