Form Up-1 - Unclaimed Properity Report
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1
2FORM UP-l SUMMARY REPORT
HOLDER NUMBER
REPORTS AND REMITTANCE are due November 1
of each reportingyear for the propertylisted that is
unclaimedasofthe precedingJune 30th:
STATE OF MISSISSIPPI
UNCLAIMED PROPERTY REPORT
Tate Reeves
State Treasurer
REPORTYEAR
Date of this report
Federal ID #
Name of Holder:
Contact Person
FOR TREASURY
USE ONLY
Mailing Address
Phone
Fax
City, State, Zip
Type of Business
State of Incorporation
Years qualified to do business in Mississippi
In compliance with the Mississippi Uniform Disposition of Unclaimed Property Act the above holder hereby reports the following property subject to the Act for the period ending June 30:
Funds held and owing which have remained unclaimed and unpaid and presumed abandoned, as reported in detail on the attached
forms, amounting in total to
$
State of
AFFIDAVIT
County/City of
I,
(Type in name of officer, owner, etc., signing)
(Type in title of person signing)
of the company, or holder, for which this report is made, being duly sworn (or affirmed) according to law do depose and
say that this report is true and contains all facts required by law to be reported.
Signature of officer, owner, etc.
Sworn to (or affirmed) and subscribed before me this
day of
(Notary Public)
MAIL REPORT & CHECK
PAYABLE TO:
State Treasurer of Mississippi
Unclaimed Property Division
P. O. Box 138
Jackson, MS
39205-0138
FILE THIS COpy ON OR BEFORE
NOVEMBER 1 WITH FORM UP-2
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