Unclaimed Property



AP-1Division of Unclaimed PropertyP O Box 2478, Richmond, VA 23218-2478 PHONE (804) 225-2393 FAX (804) 786-4653 TOLL FREE 1-800-468-1088Holder Number_____________________________________________________________________________Holder Name_______________________________________________________________________________Address___________________________________________________________________________________City___________________________________State ____________________Zip________________________Federal Tax ID______________________________________________________________________________Contact Name______________________________________________________________________________Telephone Number__________________________________________________________________________Fax Number________________________________________________________________________________E-Mail address______________________________________________________________________________State of Incorporation________________________________ State of Headquarters (if different)___________Date of Incorporation_________________________________________________________________________SIC/NAICS code______________________________________________________________________________Number of Employees________________________________________________________________________Total Assets_________________________________________________________________________________Report Year_____________ First Time Report? __ Yes __ NoTotal shares remitted: __________via DTC __________via DRP statement __________via House Account statementReported Total Amounts: _____________________Cash ___________________Security Shares______________# of Tangible AccountsType of Report: (check one) FORMCHECKBOX Regular (Annual) FORMCHECKBOX Audit FORMCHECKBOX Voluntary Compl. FORMCHECKBOX NegativeReport Media: (check one) FORMCHECKBOX Hardcopy (Paper) FORMCHECKBOX CD FORMCHECKBOX Uploaded (NAUPA file)Remittance: FORMCHECKBOX check________________check # ___________________AmountMake Checks Payable To: FORMCHECKBOX check________________check # ___________________AmountTreasurer of Virginia FORMCHECKBOX wire________________wire ID # ___________________Amount FORMCHECKBOX ACH________________ACH # ___________________Amount FORMCHECKBOX ATA / REDI________________ ID # ___________________Amount-I CERTIFY THAT I HAVE CAUSED TO BE PREPARED AND HAVE EXAMINED THIS REPORT AS TO PROPERTY PRESUMED ABANDONED UNDER THE VIRGINIA UNCLAIMED PROPERTY LAW FOR THE YEAR ENDING AS STATED, THAT I AM DULY AUTHORIZED TO EXECUTE THIS VERIFICATION BY THE HOLDER AND BY LAW AND THAT I BELIEVE THAT SAID REPORT IS TRUE, CORRECT, AND COMPLETE AS OF SAID DATE, EXCEPTING FOR SUCH PROPERTY AS HAS SINCE CEASED TO BE ABANDONED. -I CERTIFY THAT DUE DILIGENCE WAS PERFORMED ON THE FOLLOWING DATES FROM______________________________TO____________________________SIGNATURE ________________________________________________Print____________________________________TITLE ____________________________________________________________DATE ________________________________ ................
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