Form Up-1k - Holder Report Summary - Safekeeping - 2010
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1UP-1K (Rev. 06/2010)
GEORGIA DEPARTMENT OF REVENUE
UNCLAIMED PROPERTY PROGRAM
HOLDER REPORT SUMMARY
FORM UP-1K
2010
SAFEKEEPING
This form must accompany all holder reports.
DID YOU ATTACH A CD? Y [ ] N [ ] ELECTRONIC FILERS: Submit a UP-1K for each business included on the CD.
HOLDER INFORMATION
2. INSTITUTION
1. FEDERAL EMPLOYER ID#
ADDRESS
CITY, STATE, ZIP CODE
B
3. IS THIS REPORT BEING PREPARED
Y AN AGENT ON BEHALF OF THE INSTITUTION?
Y [
]
N [
]
IF YES, FURNISH AGENT NAME
AND ADDRESS:
5. TELEPHONE
4. NAME OF CONTACT PERSON
6. E-MAIL ADDRESS
(
)
7. DATE OF INCORPORATION
8. STATE OF INCORPORATION
REPORT INFORMATION
9. Number of safe deposit boxes/safekeeping items _______________________
VERIFICATION STATEMENT
I ________________________________ certify that I have caused to be prepared and have examined this
report totaling _____________ safe deposit boxes as to property presumed abandoned under the “Disposition
of Unclaimed Property Act” for the year ended ____________, that I am duly authorized to execute this verification
by the institution and that I believe said report to be true, correct and complete as of said date to the best of my
knowledge.
Printed or Typed Name of Responsible Officer
Signature of Responsible Officer
Date
Title of Responsible Officer
FOR OFFICE USE ONLY
REPORT ID
HOLDER NO.
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