Form Ap- 5 - Holder Request For Reimbursement
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3HOLDER REQUEST FOR REIMBURSEMENT
For funds paid to the Department
AP- 5 (3-08)
FOR OFFICIAL USE ONLY:
COMMONWEALTH OF PENNSYLVANIA
TREASURY DEPARTMENT
Claim Number______________________ Holder EIN_______________________
BUREAU OF UNCLAIMED PROPERTY
Date Received______________________ Prepared By______________________
PO Box 1837
Harrisburg, PA 17105-1837
(Please print or type)
PART I HOLDER INFORMATION: (see instructions for claim completion)
EIN NUMBER
NAME OF HOLDER
STREET ADDRESS
ZIP CODE
STATE
CITY
TELEPHONE
EXT
CONTACT PERSON
PART II CLAIM INFORMATION:
REPORT YEAR
FOR OFFICIAL USE ONLY:
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)
CLAIMANT(S) NAME
CLAIMANT(S) ADDRESS:
STREET ADDRESS
STATE
ZIP CODE
CITY
DATE PAID TO CLAIMANT OR DATE STOCK ORDERED
AMOUNT OF SHARES ORDERED
AMOUNT PAID
REPORT YEAR
FOR OFFICIAL USE ONLY:
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)
CLAIMANT(S) NAME
CLAIMANT(S) ADDRESS:
STREET ADDRESS
ZIP CODE
STATE
CITY
DATE PAID TO CLAIMANT OR DATE STOCK ORDERED
AMOUNT OF SHARES ORDERED
AMOUNT PAID
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