Address Line 2:

Holder Number:

Holder Name:

Federal I.D. Number:

Title:Contact Person:

Telephone Number:

05/2016

Compliance Division Unclaimed Property Unit 410-767-1700 or 1-800-782-7383

New Holder Information Form All fields are required

State:

Industry

Zip Code:City:

Address Line 2:

Location Address:

Zip Code:State:City:

Mailing Address:

Trade Name:

E-mail Address: