Form Up-1c - 2011 Holder Report Summary - Corporate Entities
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1UP-1C (Rev. 06/2011)
GEORGIA DEPARTMENT OF REVENUE
UNCLAIMED PROPERTY PROGRAM
2011 HOLDER REPORT SUMMARY
FORM UP-1C
CORPORATE 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-1C 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
(
)
12. TOTAL ASSETS
8. STATE OF INCORPORATION
9. PRIMARY BUSINESS ACTIVITY
10. NO. OF EMPLOYEES 11. ANNUAL SALES
REPORT INFORMATION
13a. Total accounts $50.00 or more
________________
13b. Dollar Value
_________________
13c. Total accounts less than $50.00
________________
13d. Dollar Value
_________________
13e. 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
CHECK NUMBER
CHECK AMOUNT
CD
CHECK DATE
DATE DEPOSITED
RECEIPT NO.
REPORT ID
HOLDER NO.
BATCH NO.
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