Form Up-1f - 2011 Holder Report Summary - Financial Entities
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1UP-1F (Rev. 06/2011)
GEORGIA DEPARTMENT OF REVENUE
UNCLAIMED PROPERTY PROGRAM
2011 HOLDER REPORT SUMMARY
FORM UP-1F
FINANCIAL ENTITIES
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-1F for each business included on the CD. NEGATIVE BALANCE REPORTS REQUIRED.
HOLDER INFORMATION
1. FEDERAL EMPLOYER ID#
2. HOLDER (Business Name)
ADDRESS
CITY, STATE, ZIP CODE
3. IS THIS REPORT BEING PREPARED BY AN AGENT ON BEHALF OF THE HOLDER?
Y [
]
N [
]
IF YES, FURNISH AGENT NAME
AND ADDRESS:
5. TELEPHONE
4. NAME OF CONTACT PERSON
6. E-MAIL ADDRESS
7. DATE OF INCORPORATION
(
)
9. NO. OF EMPLOYEES
10. ANNUAL SALES
11. TOTAL ASSETS
8. STATE OF INCORPORATION
REPORT INFORMATION
12a. Total accounts $50.00 or more
________________
12b. Dollar Value
_________________
12c. Total accounts less than $50.00
________________
12d. Dollar Value
_________________
12e. 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
Title of Responsible Officer
Date
FOR OFFICE USE ONLY
CD
CHECK NUMBER
CHECK DATE
CHECK AMOUNT
DATE DEPOSITED
BATCH NO.
RECEIPT NO.
REPORT ID
HOLDER NO.
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