Form Up-1g - Holder Report Form Government Entities - 2011
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1UP-1G(Rev. 06/11)
GEORGIA DEPARTMENT OF REVENUE
UNCLAIMED PROPERTY PROGRAM
HOLDER REPORT FORM
GOVERNMENT ENTITIES
2011
This form must accompany all holder reports
ARE YOU A 1ST TIME FILER? Y [ ] N [ ]
DID YOU ATTACH A CD? Y [ ] N [ ]
ELECTRONIC FILERS: Submit a UP-1G for each entity included on the CD. NEGATIVE BALANCE REPORTS REQUIRED.
HOLDER INFORMATION
1. FEDERAL EMPLOYER ID#
2. HOLDER (Entity Name)
ADDRESS
CITY, STATE, ZIP CODE
4. TELEPHONE
3. NAME OF CONTACT PERSON
5. E-MAIL ADDRESS
(
)
REPORT INFORMATION
INTANGIBLE PROPERTY
6a. Total accounts $50.00 or more ________________________
6b. Dollar Value $ ______________________
6c. Total accounts less than $50.00 ________________________
6d. Dollar Value $ ______________________
6e. Report Total $ _____________________
VERIFICATION STATEMENT
I,
certify that I have caused to be prepared and have examined this report
totaling $
as to property presumed abandoned under the “Disposition of Unclaimed Property Act”
for the year ended as stated, that I am duly authorized to execute this verification by the holder and that I believe said report
to be true, correct and complete as of said date to the best of my knowledge.
Signature of Responsible Officer
Printed or Typed Name of Responsible Officer
Date
Title of Responsible Officer
FOR OFFICE USE ONLY
CD
CHECK NUMBER
CHECK DATE
CHECK AMOUNT
DATE DEPOSITED
RECEIPT NO.
REPORT ID
HOLDER NO.
BATCH NO.
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