Form Ap-7 - Holder Reporting Errors Page 3
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3PART II CLAIM INFORMATION: (continued)
TREASURY USE ONLY:
REPORT YEAR
Property ID Number__________________________________
PROPERTY CODE
ACCOUNT / REFERENCE NUMBER / CHECK NUMBER
IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL
REPORTED OWNER(S) NAME (exactly as indicated on report)
REASON FOR ERROR
AMOUNT
NUMBER OF SHARES
TREASURY USE ONLY:
REPORT YEAR
Property ID Number__________________________________
PROPERTY CODE
ACCOUNT / REFERENCE NUMBER / CHECK NUMBER
IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL
REPORTED OWNER(S) NAME (exactly as indicated on report)
REASON FOR ERROR
AMOUNT
NUMBER OF SHARES
TOTAL AMOUNT (all pages)
$0.00
TOTAL NUMBER OF SHARES (all pages)
0.0000
PART III HOLDER CERTIFICATION:
I,
, a duly authorized
Name of Representative
Title
corporate officer of the holder listed above, do hereby certify that the above listed funds or shares, which were listed in the Report of
Abandoned and Unclaimed Property filed by the holder have been remitted in error. The holder therefore requests reimbursement
for such payment.
Signature of Corporate Officer _______________________________
Date _____________________
Sworn to and subscribed before me this _________ day of _________________, 20______.
COMMONWEALTH OF PENNSYLVANIA
____________________________________
TREASURY DEPARTMENT
Notary
BUREAU OF UNCLAIMED PROPERTY
PO Box 1837
My commission expires:_____________ ________
PAGE 3 OF 3
Harrisburg, PA 17105-1837
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