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State of North Carolina Form ASD-159 Unclaimed Property Verification and Checklist North Carolina Department of State Treasurer Department of State Treasurer Janet Cowell State Treasurer 325 North Salisbury Street Raleigh North Carolina 27603-1385 919 508-1000 Street Raleigh North Carolina 27603-1385 Tel 919 508-1000 Web www. Nccash. com/reporting www. nccash. com/reporting All Non-Life Insurance Holders Reporting Period July 1 2011 through June 30 2012 Due November 1 2012 HOLDER ID If Known HOLDER NAME DATE OF INCORPORATION MAILING ADDRESS CITY STATE ZIP CODE CONTACT PHONE NUMBER OF EMPLOYEES ----- FEDERAL IDENTIFICATION NUMBER Every person corporation or other business association banking or financial organization insurance company utility court or public authority etc. reporting unclaimed property must complete this form ASD-159. Witness my hand and official seal this day of 20 My Commission expires 20 Signature of Notary FOR OFFICE USE ONLY CD OR DISKETTE REPORT IMPORT LOADED KEYED BALANCED COMMITED RECEIPT ID STOCK ID CUSIP SYMBOL CERTIFICATE DTC DATE CUSTODIAN REV 07/2012 ASD-159 Class Code Dormant Period CLASS CODES AND DORMANCY PERIODS ACCOUNT BALANCES DUE SECURITIES INSURANCE AC01 Checking Accounts AC02 Savings Accounts AC03 Matured CD or Savings Cert. AC04 Christmas Club Funds IN03 AC05 Money-Deposit to Secure Funds AC06 Security Deposits Individual Policy Benefits or Claim Payments Group Policy Benefits or Claim Benefits IN01 IN02 SC01 Dividends SC02 Interest Bond Coupons SC03 Principal Payments SC05 Profits IN04 Proceeds Due Beneficiaries Proceeds from Matured Policies Endowments or Annuities SC04 Equity Payments SC06 Funds Paid to Purchase Shares IN05 Premium Refunds AC07 Unidentified Deposits IN06 AC08 Suspense Accounts AC09 Individual Retirement Accounts IN07 Unidentified Remittances Other Amounts Due Under Policy Terms SC07 Funds For Stocks Bonds Shares of Stock Returned by Post SC08 Office IN08 Agent Credit Balances IN09 Aggregate Trust Property 50 SC09 Cash for Fractional Shares Unexchanged Stock Fractional SC10 Shares of Successor Corp SC11 Other Cert of Ownership Underlying Shares or Other SC12 Outstanding Certificates Funds for Liquidation Redemption of SC13 Surrendered Stocks or Bonds SC14 Debentures SC15 US Govt Securities SC16 Mutual Fund Shares SC17 Warrants Rights SC18 Matured Bond Principal SC19 Dividend Reinvestment Plans SC20 Credit Balances Aggregate Security Related Cash SC99 50 AC99 Aggregate Account Balances 50 UNCASHED CHECKS TRUST INVESTMENTS AND ESCROW ACCOUNTS CK01 Cashier s Checks CK02 Certified Checks TR01 Paying Agent Accounts CK03 Registered Checks TR02 Undelivered/Uncashed Dividends CK04 Treasurer s Checks TR03 Funds held in Fiduciary Capacity CK05 Drafts TR04 Escrow Accounts CK06 Warrants TR05 Trust Vouchers CK07 Money Orders TR99 CK08 Traveler s Checks CK09 Foreign Exchange Checks MI01 Net Revenue Interest CK10 Expense Checks MI02 Royalties CK11 Pension Checks MI03 Overriding Royalties CK12 Credit Checks or Memos MI04 Production Payments UT01 Utility Deposits CK13 Vendor Checks MI05 Working Interest UT02 Membership Fees CK14 Checks Written Off to Income MI06 Bonuses UT03 Refunds or Rebates CK15 Other Outstanding Official Checks MI07 Delay Rentals UT04 Capital Credit Distributions CK16 CD Interest Checks MI08 Shut-In Royalties UT99 Aggregate Utility Property 50 MI09 Minimum Royalties MI99 Aggregate Mineral Interests 50 CK99 Aggregate Uncashed Checks 50 SAFE DEPOSIT BOXES SAFEKEEPING SD01 Safe Deposit Box Contents SD02 Safekeeping/Loan Collateral SD03 Other Tangible Property MINERAL PROCEEDS MINERAL INTERESTS MS01 Wages Payroll Salary MS02 Commissions MS03 Workers Compensation Benefits Payment for Goods Services Customer Overpayments 3/5 MS06 MS07 Unrefunded Overcharges MS08 Accounts Payable MS09 Credit Balances 3 Retail/5 Other MS10 Discounts Due MS11 MS12 Refunds Due Unredeemed Gift Certificates MS13 MS14 Unclaimed Loan Collateral Pension Profit Sharing Plans IRA KEOGH MS15 Dissolution or Liquidation Misc Outstanding Checks CT01 Escrow Funds CT02 Condemnation Awards CT03 Missing Heirs Funds CT05 Other Court Deposits CT06 Real Property Proceeds CT07 Cash Bonds CT08 Partial Payments CT09 Judgments CT10 Trust Funds CT99 Aggregate Court Deposits 50 MS16 MS17 Misc Intangible Prop DM01 Cash MS18 Suspense Liabilities DM02 Stock Aggregate Demutualization Property DM99 50 MS19 Layaway Deposits Payments MS20 Rents MS99 Aggregate Misc Checks Intangible Personal Property 50 DEMUTUALIZATION MISCELLANEOUS CHECKS INTANGIBLE PERSONAL PROPERTY MS05 COURT DEPOSITS ZZZZ Properties Not Identified Above MS04 Aggregate Safe Deposit Boxes UTILITIES This property should be reported on Form ASD-127 prior to submitting the property. Specify Date Range i.e. the date of the first and last payments on Periodic Payments i.e. outstanding dividend checks if multiple payments of same property type are being reported for a single property owner. REPORT TOTAL NAME-PRINT INTEREST PENALTY TITLE TOTAL REMITTANCE SIGNATURE TOTAL SHARES NOTARY PUBLIC CERTIFICATION State of County of I a notary public for said county do hereby certify that SEAL personally appeared before me this date and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal this day of 20 My Commission expires 20 Signature of Notary FOR OFFICE USE ONLY CD OR DISKETTE REPORT IMPORT LOADED KEYED BALANCED COMMITED RECEIPT ID STOCK ID CUSIP SYMBOL CERTIFICATE DTC DATE CUSTODIAN REV 07/2012 ASD-159 Class Code Dormant Period CLASS CODES AND DORMANCY PERIODS ACCOUNT BALANCES DUE SECURITIES INSURANCE AC01 Checking Accounts AC02 Savings Accounts AC03 Matured CD or Savings Cert. AC04 Christmas Club Funds IN03 AC05 Money-Deposit to Secure Funds AC06 Security Deposits Individual Policy Benefits or Claim Payments Group Policy Benefits or Claim Benefits IN01 IN02 SC01 Dividends SC02 Interest Bond Coupons SC03 Principal Payments SC05 Profits IN04 Proceeds Due Beneficiaries Proceeds from Matured Policies Endowments or Annuities SC04 Equity Payments SC06 Funds Paid to Purchase Shares IN05 Premium Refunds AC07 Unidentified Deposits IN06 AC08 Suspense Accounts AC09 Individual Retirement Accounts IN07 Unidentified Remittances Other Amounts Due Under Policy Terms SC07 Funds For Stocks Bonds Shares of Stock Returned by Post SC08 Office IN08 Agent Credit Balances IN09 Aggregate Trust Property 50 SC09 Cash for Fractional Shares Unexchanged Stock Fractional SC10 Shares of Successor Corp SC11 Other Cert of Ownership Underlying Shares or Other SC12 Outstanding Certificates Funds for Liquidation Redemption of SC13 Surrendered Stocks or Bonds SC14 Debentures SC15 US Govt Securities SC16 Mutual Fund Shares SC17 Warrants Rights SC18 Matured Bond Principal SC19 Dividend Reinvestment Plans SC20 Credit Balances Aggregate Security Related Cash SC99 50 AC99 Aggregate Account Balances 50 UNCASHED CHECKS TRUST INVESTMENTS AND ESCROW ACCOUNTS CK01 Cashier s Checks CK02 Certified Checks TR01 Paying Agent Accounts CK03 Registered Checks TR02 Undelivered/Uncashed Dividends CK04 Treasurer s Checks TR03 Funds held in Fiduciary Capacity CK05 Drafts TR04 Escrow Accounts CK06 Warrants TR05 Trust Vouchers CK07 Money Orders TR99 CK08 Traveler s Checks CK09 Foreign Exchange Checks MI01 Net Revenue Interest CK10 Expense Checks MI02 Royalties CK11 Pension Checks MI03 Overriding Royalties CK12 Credit Checks or Memos MI04 Production Payments UT01 Utility Deposits CK13 Vendor Checks MI05 Working Interest UT02 Membership Fees CK14 Checks Written Off to Income MI06 Bonuses UT03 Refunds or Rebates CK15 Other Outstanding Official Checks MI07 Delay Rentals UT04 Capital Credit Distributions CK16 CD Interest Checks MI08 Shut-In Royalties UT99 Aggregate Utility Property 50 MI09 Minimum Royalties MI99 Aggregate Mineral Interests 50 CK99 Aggregate Uncashed Checks 50 SAFE DEPOSIT BOXES SAFEKEEPING SD01 Safe Deposit Box Contents SD02 Safekeeping/Loan Collateral SD03 Other Tangible Property MINERAL PROCEEDS MINERAL INTERESTS MS01 Wages Payroll Salary MS02 Commissions MS03 Workers Compensation Benefits Payment for Goods Services Customer Overpayments 3/5 MS06 MS07 Unrefunded Overcharges MS08 Accounts Payable MS09 Credit Balances 3 Retail/5 Other MS10 Discounts Due MS11 MS12 Refunds Due Unredeemed Gift Certificates MS13 MS14 Unclaimed Loan Collateral Pension Profit Sharing Plans IRA KEOGH MS15 Dissolution or Liquidation Misc Outstanding Checks CT01 Escrow Funds CT02 Condemnation Awards CT03 Missing Heirs Funds CT05 Other Court Deposits CT06 Real Property Proceeds CT07 Cash Bonds CT08 Partial Payments CT09 Judgments CT10 Trust Funds CT99 Aggregate Court Deposits 50 MS16 MS17 Misc Intangible Prop DM01 Cash MS18 Suspense Liabilities DM02 Stock Aggregate Demutualization Property DM99 50 MS19 Layaway Deposits Payments MS20 Rents MS99 Aggregate Misc Checks Intangible Personal Property 50 DEMUTUALIZATION MISCELLANEOUS CHECKS INTANGIBLE PERSONAL PROPERTY MS05 COURT DEPOSITS ZZZZ Properties Not Identified Above MS04 Aggregate Safe Deposit Boxes UTILITIES This property should be reported on Form ASD-127 prior to submitting the property. .