Form Ap- 1 Neg - Negative Reporting Form For Abandoned And Unclaimed Property

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Negative reportiNg form for abaNdoNed aNd uNclaimed property
ap- 1 Neg
Robert M. McCord, State Treasurer
COMPANY INFORMATION:
Company Name _______________________________________________________________________________________
Federal ID Number (FEIN) _______________________________________________________________________________
Contact Name ________________________________ Phone _______________ Email ___________________________
Address 1 ___________________________________________________________________________________________
City _________________________________________________ State _________ Zip Code ________________________
County _________________________________________________ State of Incorporation _________________________
Assets $ _________________________________ Annual Sales $ ___________________
Number of Employees _________________ report year _________________________
Industry Type: (check box)
__ Management of Companies
__ County Controller
__ Trucking
__ Administrative & Support
__ County/State Treasurer
__ Transportation
__ Agriculture, Forestry, Fishing
__ Educational Services
__ County Clerks of Court & Proth
__ Police Departments
__ Mining & Oil/Gas
__ Health Care & Social Assistance
__ County Sheriff
__ Correctional Institutions
__ Utilities
__ Arts, Entertainment & Recreation
__ County/State Nursing Homes
__ Other State Government Agencies
__ Construction
__ Accommodation & Food Service
__ Manufacturing
__ Finance
__ Wholesale Trade
__ Other Services (Except Public)
__ Retail
__ Insurance
__ Newspapers & TV Broadcasting
__ Public Administration
__ Information Technology
__ General
__ Finance & Insurance
__ County
__ Municipal Authorities
__ Real Estate Rental & Lease
__ School District
__ Consulting
__ Professional & Scientific
HOLDER VERIFICATION:
The Pennsylvania Treasury, Bureau of Unclaimed Property requires the signature of the Chief Financial Officer or other
corporate officer responsible for the financial operations of the company.
The undersigned hereby verifies that an annual review of the books and records of
__________________________________________________________________________ has been performed.
(name of company)
As a result of this review, we can definitively state that this company is not in possession of any unclaimed property that is
due and reportable to the Commonwealth of Pennsylvania.
mail to: Bureau of Unclaimed Property, P.O. Box 1837, Harrisburg, PA 17105
______________________________________________________________________________ has policies and
(name of company)
procedures in place to account for dormant property and eventually report unclaimed property to the Commonwealth of
Pennsylvania in accordance with 72 P.S. § 1301 et.seq.
_____________________________________________________________________________ understands that
(name of company)
unreported and/or undelivered property is subject to 12% interest in accordance with 72 P.S. §§ 1301.24, and other penalties
as provided for in statute, including but not limited to 72 P.S. § 1301.25 (relating to penalties). The undersigned herby verifies
that the statements set forth in this holder report are true, and acknowledges that any false statements contained therein
are subject to the penalties of 18 Pa. C.S.A § 4904 (relating to unsworn falsification to authorities)
____________________________________________________
___________________________________
Signature
Date
____________________________________________________
___________________________________
Print Name
Title

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