Form Ap-1 - Report Of Abandoned And Unclaimed Property Verification And Checklist - Pennsylvania

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AP- 1
REPORT OF AbANDONED AND UNClAImED PROPERTY VERIFICATION AND CHECklIST
Robert M. McCord, State Treasurer
HOLDER INFORMATION:
Holder’s Name ______________________________________________________________________________
Federal EIN Number __________________________________________________________________________
Contact Name ___________________________ Phone _____________ Email ________________________
Address 1 __________________________________________________________________________________
City ____________________________________________ State _______ Zip Code _____________________
County ________________________________________ State of Incorporation _________________________
Assets $ __________________________ Annual Sales $ ___________________
Number of Employees ______________ Report Year _____________________
Industry Type: (check box)
__ Management of Companies
__ County Controller
__ Trucking
__ Administrative & Support
__ County/State Treasurer
__ Transportation
__ Agriculture, Forestry, Fishing
__ Educational Services
__ County Clerks of Court & Proth
__ Police Departments
__ Mining & Oil/Gas
__ Health Care & Social Assistance
__ County Sheriff
__ Correctional Institutions
__ Utilities
__ Arts, Entertainment & Recreation
__ County/State Nursing Homes
__ Other State Government Agencies
__ Construction
__ Accommodation & Food Service
__ Manufacturing
__ Finance
__ Wholesale Trade
__ Other Services (Except Public)
__ Retail
__ Insurance
__ Newspapers & TV Broadcasting
__ Public Administration
__ Information Technology
__ General
__ Finance & Insurance
__ County
__ Municipal Authorities
__ Real Estate Rental & Lease
__ School District
__ Consulting
__ Professional & Scientific
Is this the first time your organization has filed an abandoned and unclaimed property report to the Commonwealth of Pennsylvania?
YES ____ NO ____
Have you ever reported under another company name? YES ____ NO ____
If so, under what company name? _________________________________ Federal EIN # ____________
Please fill in the blanks below for a positive report. Report should be signed by Company President, Chief Executive Officer or
Chief Financial Officer. (For negative reports, please use the new ‘AP-1 Neg’ form.)
I have prepared and examined this AP-1 report consisting of _______________ pages totaling $___________________ as to
property presumed abandoned under the Pennsylvania Disposition of Abandoned and Unclaimed Property Act (DAUPA) for
the year ended as stated. I verify this report is accurate and complete to the best of my knowledge and belief as of said date,
excepting for such property as has since ceased to be abandoned.
Please check if your payment is a Wire Transfer
HOLDER VERIFICATION: The undersigned hereby verifies that the statements set forth in this holder report are true, and
acknowledges that any false statements contained therein are subject to the penalties of 18 Pa. C.S.A. § 4904 (relating to
unsworn falsification to authorities).
____________________________________________________
___________________________________
Signature
Date
____________________________________________________
___________________________________
Print Name
Title
Report for Period Ended December 31, _________
mail to: Commonwealth of Pennsylvania
Commonwealth of Pennsylvania-Unclaimed Property
Unclaimed Property
Lockbox 53473
P.O. Box 8500-53473
101 N. Independence Mall East
Philadelphia, PA 19178-3473
Philadelphia, PA 19106
Reference Field: Lockbox #053473
(

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