Form Ap-1 Ins - Report Of Unclaimed Property
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1
2FORM AP-1 INS
REV 8/2014
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF THE STATE TREASURER
UNCLAIMED PROPERTY DIVISION
One Ashburton Place, 12th Floor
Boston, Massachusetts 02108-1608
(617) 367-3900
Deborah B. Goldberg
Treasurer and Receiver General
REPORT OF UNCLAIMED PROPERTY AP-1
In accordance with M.G.L. c. 200A, every person, corporation, or other business association, banking or financial organization,
life insurance corporation, utility, court or public authority is required to complete this form and submit it together with their
unclaimed property to the State Treasury, Unclaimed Property Division, by November 1 of each year (May 1 for Life Insurance
companies). All reports must be filed electronically. A preformatted diskette package is available upon request at no charge to
the holder by contacting the Unclaimed Property Division at the address and telephone number listed above. Reports not
conforming to the prescribed reporting requirements will be returned to the holder and may be subject to fines and penalties
(M.G.L. c 200A s 12). Please refer to the enclosed instructions.
HO
*Unclaimed Property Holder number _______________________
Federal Employer Tax I.D.# ____________________
Holder Name ___________________________________________
Contact Person _________________________________________
Telephone # ____________________________________
List on a separate sheet the name and address of all
Address _______________________________________________
previous holders of the property, if you are a successor
_______________________________________________
or if your company name has changed during the time
period in which you have held the property.
_______________________________________________
*UNCLAIMED PROPERTY HOLDER NUMBER
_______________________________________________
is the number assigned to you by the Unclaimed
Did you file a report of unclaimed property last year? __________
Property Division.
Primary business activity of your company ____________________________________________________________________
Parent Company ___________________ State of Incorporation _________________ Date of Incorporation ______________
Verification for period ended _____________________
Check box if filing a Negative Report ($0.00)
Type of Report included (check one): CD _____________ Diskette ____ FTP ________
Name of Service Bureau __________________________ Telephone # ___________________________
REPORT TOTALS
(a) AGGREGATE TOTAL
$ _________________________________
(b) OWNER TOTAL
$ _________________________________
TOTAL OF CASH AMOUNT REPORTED
$ _________________________________
TOTAL NUMBER OF SHARES REPORTED
no. _______________________________
(If you are reporting more than one issue list each and the totals on a separate sheet.)
Number Of Owners Reported
no. _______________________________
Check box if remittance is sent by Electronic Funds Transfer (EFT)
VERIFICATION
I,______________________________________, being duly sworn, on oath depose and state that I have caused to be
prepared and have examined this report of property presumed abandoned under the Massachusetts Unclaimed Property Law
Chapter 200A, and that I am duly authorized to execute this verification and believe said report is true, correct and complete
as of said date.
On this ____ day of ____________, 20___, before me, the undersigned notary
public, personally appeared________________________(name of document
signer), proved to me through satisfactory evidence of identification, which were
________________________, to be the person who signed the preceeding or
attached document in my presence, and who swore or affirmed to me that the
contents of the document are truthful and accurate to the best of (his)(her)
knowledge and belief.
____________________________(official signature and seal of notary)
(over)
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