Holder Information
HOLDER NAME (Complete Name of Company or Institution)
HOLDER FEIN (If Known)
LOCATION (Physical Address)
LOCATION (Mailing Address)
Owner #1 Information
OWNER 1 NAME (Last, First, and Middle)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
ADDRESS (Street, City, State, Zip)
DRIVER’S LICENSE # AND STATE
EMAIL ADDRESS
OWNER RELATIONSHIP CODE
Owner #2 Information (If applicable)
OWNER 2 NAME (Last, First, and Middle)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
ADDRESS (Street, City, State, Zip)
DRIVER’S LICENSE # AND STATE
EMAIL ADDRESS
OWNER RELATIONSHIP CODE
Safe Deposit Box Information
Safe Deposit Box Number _______________________________
Photograph
#
Description of Items
Past Due Rent _____________________________
Estimated
Value
Office Use Only
D
S
AA
IB
REV 1/2017
Date
ASD-127
Form ASD-127: Abandoned Tangible Property
Owner #1 Information
OWNER 1 NAME (Last, First, and Middle)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
ADDRESS (Street, City, State, Zip)
DRIVER’S LICENSE # AND STATE
EMAIL ADDRESS
OWNER RELATIONSHIP CODE
Owner #2 Information (If applicable)
OWNER 2 NAME (Last, First, and Middle)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
ADDRESS (Street, City, State, Zip)
DRIVER’S LICENSE # AND STATE
EMAIL ADDRESS
OWNER RELATIONSHIP CODE
Safe Deposit Box Information
Safe Deposit Box Number _______________________________
Photograph
#
Description of Items
Past Due Rent _____________________________
Estimated
Value
Office Use Only
D
S
AA
IB
REV 1/2017
Date
ASD-127
Form ASD-127: Abandoned Tangible Property
New Reporting Requirements
The North Carolina General Assembly amended the statutory requirements of G.S. 116B-55, effective October 1, 2015, to better enable
Holders and the North Carolina Department of State Treasurer’s (NCDST) Unclaimed Property Division (UPD) to find rightful owners of
tangible property.
Holders should be aware that the new provisions:
•
Allow NCDST to require a photograph or digital image of each unclaimed property item be provided by the holder.
•
Require a good-faith estimated value for each item be provided by the holder.
•
Require firearms or contents that pose a potential public safety issue, or contents that are regulated by another authority, to be
delivered to local law enforcement or the appropriate authority, and not to UPD.
General Instructions for Completing ASD-127
1.
Before submitting forms or property, please be sure you are in compliance with the provisions of General Banking Statute 53C-613, G.S. 116B-59 and the new reporting requirements of G.S. 116B-55, effective October 1, 2015.
2.
Please type or print in black ink.
3.
All safe deposit box owner information, including owner relationship, for all owners and those who have authorized access to the
safe deposit box, is required, if known by the holder.
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
ES – Estate
EX – Executor or Executrix
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
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 list of Owner Relationship Codes with definitions.
4.
Photographs or digital images of each reported item should be submitted with the initial ASD-127 and ASD-159T reports.
Photographs or digital images should capture any identifying features. Items of the same type may be grouped together, but must
be identifiable in the photograph or digital image. Photographs or digital images should be uniquely numbered. Photographs of
miscellaneous papers are not required. The following documents are NOT considered miscellaneous papers: military discharge
papers, savings bonds, stock certificates, traveler or cashier checks, adoption papers, and life insurance policies.
5.
It is important that ALL items are reported and described to accurately reflect the contents of the safe deposit box.
6.
Provide a good faith estimated value for each item included on the report. For currency and coins, list their face value.
7.
Mail the completed ASD-127 and completed ASD-159T, along with all photographs or digital images to:
North Carolina Department of State Treasurer
Unclaimed Property Division
ATTN: Granger Roseberry
3200 Atlantic Ave.
Raleigh, NC 27604-1668
8.
Upon receipt and review of the submitted ASD-127 and ASD-159T, UPD will return a copy of these reports to you with instructions
for how to proceed with each item. Each item will have one of the three instructions checked:
9.
a.
“D” – Holder is to destroy or otherwise dispose of the item.
b.
“S” – Holder is to submit the item to UPD.
c.
“AA” – Holder is to submit the item to the appropriate authority.
Submit all currency and coins as is. Do not submit a check in place of currency or coins.
10. Under no circumstances should firearms be delivered to UPD. All firearms are to be delivered to a local law enforcement agency.
11. Prior to shipping safe deposit box contents to UPD, please review the report to confirm all safe deposit box contents instructed by
UPD to be delivered will be shipped. If contents of a safe deposit box have been returned to the owner, please notate “Contents
claimed by owner” and the date owner claimed the contents next to the safe deposit box number.
REV 1/2017
ASD-127
Form ASD-127: Abandoned Tangible Property
Specific Instructions for Completing ASD-127
HOLDER INFORMATION
HOLDER NAME
Complete name of the company or institution
HOLDER FEIN
Company’s Federal Employer Identification Number or Tax ID number
SAFE DEPOSIT BOX OWNER INFORMATION (IF KNOWN) FOR EACH OWNER, INCLUDING THOSE WITH AUTHORIZED
ACCESS TO THE SAFE DEPOSIT BOX
OWNER NAME
Last Name, First, Middle for the person leasing the safe deposit box or person with authorized access to
the safe deposit box.
OWNER ADDRESS
Last known address for owner
SOCIAL SECURITY #
Nine-digit social security number of the owner
DATE OF BIRTH
Date of birth in MM-DD-YY format
DL # AND STATE
Driver’s license number and state of issuance
EMAIL ADDRESS
Known email address
OWNER RELATIONSHIP
CODE
Where there are multiple owners or multiple persons with access to the safe deposit box, the relationship
between any of the named owner(s) and/or those authorized to access the safe deposit box. A list of
owner relationship codes and definitions can be found at www.nccash.com/reporting.
SAFE DEPOSIT BOX CONTENTS INFORMATION
PAST DUE RENT
Amount of past rent due only—do not include drilling fees. If multiple owners, add a notation of the
amount owed by each owner in accordance with the lease agreement.
PHOTOGRAPH #
Unique number assigned to photograph or digital image of tangible item.
DESCRIPTION OF
ITEMS
Items must be described in detail, noting any unique or identifying marks or characteristics for each piece
of property and be accurately quantified. Submit just ONE item per line. When grouping items of the
same type, indicate the quantity in the description. (Example: 12 buffalo head nickels, 5 gold bracelets).
The following papers should not be aggregated and reported as miscellaneous items: military discharge
papers, savings bonds, stock certificates, traveler or cashier checks, adoption papers, and life insurance
policies. These documents should be listed individually on the ASD-127.
ESTIMATED VALUE
The estimated value of currency and coins is their face value. A good-faith estimated value of each
individual item is required by statute. Please use your best judgement in providing an estimated value. A
good faith estimate is required for all contents within a safe deposit box. Reports received that do not
contain an estimated value will be returned with a request for an estimated value.
OFFICE USE ONLY
Upon receipt of Form ASD-127, ASD-159T, and photographs or digital images, the Unclaimed Property
Division (UPD) will review all items and indicate in this space how to proceed with each individual
property. UPD will indicate if the item is to be destroyed or otherwise disposed of by the holder (D),
submitted to the UPD (S), or turned over to the appropriate authority (AA). Columns IB and Date are for
internal purposes only.
REV 1/2017
ASD-127