Form Up-1 - Unclaimed Property Report-Holder Information - 2006

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UP-1

State of New Jersey

08-06

Department of the Treasury

Unclaimed Property

Phone (609) 292-9200

P.O. Box 214

Fax

(609) 984-0593

Trenton, New Jersey 08695-0214

UNCLAIMED PROPERTY REPORT-HOLDER INFORMATION

Property Abandoned as of : June 30, _____

Holder ID #

December 31, _____

Holder Federal ID #: _____________________________________________

Business Code: ____________________________

Agent Name ______________________________________________________________

Holder Name & Mailing Address

Report Contact: _______________________________

Telephone Number: ___________________________

Fax number: __________________________________

State of Incorporation: __________________________

Date of Incorporation: __________________________

Contact Mailing Address: ______________________________________________________________________________

Report Contact E-mail Address: _________________________________________________________________

If this report includes property held by subsidiary companies, attach a list of the names and Federal Tax ID numbers of those companies. ___________

List the name(s) and Federal Tax ID number(s) of all previous holders of property if you are a successor. If you have changed your name during the

time in which you held the property, list the prior name(s) and Federal Tax ID Number(s):

Electronic Media _________ Paper Report UP-2 ________ (20 properties or less)

REPORT TOTAL

NUMBER OF

CASH

SECURITIES

NUMBER OF ITEMS

PAGES/MEDIA

$___________________________

_____________________

____________________

Make checks payable to “Treasurer, State of New Jersey”. Securities registered in the nominee name: Neary Penco

If you are reporting securities, please fill this section out completely.

Are All Splits Included:

Yes _______ No _______ Dates _____________________

Explanation: _____________________________________________________________________________________________

Are All Spinoffs Included:

Yes _______ No _______ Dates _____________________

Explanation: _____________________________________________________________________________________________

Is the issue remitted the same as the issue in the owner’s possession? Yes _______ No _______

CERTIFICATION:

I hereby certify that this report was prepared on _______________ and is a true and accurate statement of all unclaimed property held as of the close of

the report cycle, updated for appropriate interest/income/dividends to the date of this report. I am aware that if any of the foregoing statements made by

me are willfully false, I am subject to punishment according to the law.

Signature: _______________________________________ Title: __________________________________________ Date: ___________________

________________________________________________________________________________________________________________________

FOR OFFICE USE ONLY

Report Status: ___________

Cash Remitted: $_______________________________ Securities Remitted:_____________________________

Receipt IDs ________________________________________________________ Stock ID #s: __________________________________________

Report ID: _______________________________ Date: ____________________ Employee: _________________________________________

Owners Added Date: _____________ Employee: __________________ Cleared Date: _________________ Employee: __________________

New Jersey Is An Equal Opportunity Employer

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