Application for Extension of Time to File Unclaimed Property Report

HOLDER INFORMATION

Holder Name

FEIN or TIN

Address

Contact Phone #

City, State, Zip Code

Contact Fax #

Contact Person Name

State of Incorp.

Contact Person Title

Report Year

I request an extension of (please check one):

	All Holders except Life Insurance Companies	Life Insurance Companies
30 days until	December 1, 2008	June 1, 2009
60 days until	January 1, 2009	July 1, 2009
90 days until	February 1, 2009	August 1. 2009
120 days until	March 1, 2009	September 1, 2009

from the original due date of November 1, 2008 (May 1, 2009 for Life Ins Co and issuers of Gift Certificate/obligations and stored value cards) to file the Annual Unclaimed Property Report for the company listed above.

Signature

Title or Agent Relationship

Print Name

Date

Reason for Extension

INSTRUCTIONS: Use this application to obtain an extension of time to file your Annual Unclaimed Property Report beyond November 1 (May 1 for Life Ins Co). Please include your company's Federal Tax ID (FEIN). Specify how long an extension you need and why. Mail this completed application form to the Office of the State Treasurer, Attn: Unclaimed Property, 39 State House Station, Augusta, ME 04333-0039 or fax your application to 207-287-2367. We will reply by fax.