Form Ap1 - Report Of Unclaimed Property
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1COMMONWEALTH OF VIRGINIA
For State Use Only
DEPARTMENT OF THE TREASURY
CHECK AMOUNT
__________
Division of Unclaimed Property
CHECK # _________________
P.O. Box 2478
DEPOSIT DATE ____________
INITIALS __________________
Richmond, VA 23218
INTEREST PAYMENT AMOUNT
(
804) 225-2393 Fax (804) 786-4653
$__________________________
Toll Free 1-800-468-1088
AP1 FORM FOR REPORT OF UNCLAIMED PROPERTY
Holder Name:
Holder Number:
Address:
Zip
City:
State:
Code:
1. If the address above is incorrect, please correct here:
2. Contact Person:
Name:
Title:
Address:
Department:
City:
State:
Zip Code:
Phone No.:
3. Please provide an e-mail address:
Fax No.:
ABOUT THIS BUSINESS ENTITY:
5. Standard Industry
4.
Federal Employer Identification Number
Code
6. State of Incorporation (or locality where business license is filed if not incorporated)
8. Primary Business
7. Date of Incorporation
Activity
$
9. Annual Gross Income
Assets $
# of Employees
ABOUT THIS REPORT:
10. Date(s) Due Diligence was Performed
11. This report is for Report Year and the type of report is
REGULAR
AUDIT
NEGATIVE
OTHER
12. This report has the following media attached to report the property details:
REPORT UPLOADED TO WEBSITE
DISKETTE/CD
HARD COPY-PAPER, CONSISTING OF
PAGES
13. This is the first time this business entity has filed an Unclaimed Property Report
YES
NO
14. Property types on this report include:
CASH
SECURITIES
MUTUAL FUNDS
TANGIBLE PROPERTY
IMPORTANT NOTICE:
Your remittance must accompany this report and an authorized representative of your
business must complete the certification that follows. Please complete the summary information on the reverse of this
page, and mail your report and remittance to the address at the top of this form. Pursuant to §55-210.26:1 of the Code
of Virginia, interest and penalties may be imposed for failure to report and remit as required.
I, ___________________________, CERTIFY THAT I HAVE CAUSED TO BE PREPARED AND I HAVE EXAMINED THIS REPORT
AS TO PROPERTY PRESUMED ABANDONED UNDER THE VIRGINIA UNCLAIMED PROPERTY LAW FOR THE YEAR ENDING
AS STATED, THAT I AM DULY AUTHORIZED TO EXECUTE THIS VERIFICATION BY THE HOLDER AND BY LAW AND THAT I
BELIEVE THAT SAID REPORT IS TRUE, CORRECT, AND COMPLETE AS OF SAID DATE, EXCEPTING FOR SUCH PROPERTY
AS HAS SINCE CEASED TO BE ABANDONED. THIS REPORT TOTALS #
PROPERTIES FOR $____________ AND #
SHARES.
SIGNATURE:
TITLE:
DATE:
FOR STATE USE ONLY
POSTMARK DATE
BATCH #
HOLDER UPDATED
BALANCED BY
DATE COMPLETED
# OF OWNERS
# SHARES REPORTED
ENTERED BY
DATE BEGAN
DATE COMPLETED
REPORT VERIFIED
DATE CLOSED
AP1-print Revised 10/12/2007
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Parent category: Financial