Form Up-1 - Unclaimed Property Report - Holder Information printable pdf download

UP-1

State of New Jersey

5-98, R-4

DEPARTMENT OF THE TREASURY

UNCLAIMED PROPERTY

Phone (609) 984-5214

PO Box 214

FAX # (609) 292-9439

Trenton, New Jersey 08646-0214

UNCLAIMED PROPERTY REPORT - HOLDER INFORMATION

Holder’s Federal Employer Tax ID No: _________________________________________

Property Abandoned as of:

June 30, ___________

Business code:_____________________________________________________________

December 31, ___________

Holder Name:___________________________________________________________________________________________________________________

Holder Address:_________________________________________________________________________________________________________________

City, State, Zip Code:_____________________________________________________________________________________________________________

State of Incorporation:________________________________ or State of Incorporation of the Intermediary:_______________________________________

Report Contact:_____________________________________________________________

Phone Number: (________) ____________________________

Mailing Address:_________________________________________________________________________________________________________________

If this report includes property held by subsidiary companies, list the names and Federal Tax ID numbers of those companies:

_______________________________________________________________________________________________________________________________

List the name(s) and Federal Tax ID number(s) of all previous holders of the property if you are a successor. If you have changed your name during the time

in which you held the property, list the prior name(s) and Federal Tax ID Number(s):

_______________________________________________________________________________________________________________________________

Magnetic Media

Paper Report UP-2

REPORT TOTAL

NUMBER OF

CASH

SECURITIES

NUMBER OF ITEMS

PAGES / MEDIA

$___________________________

___________________________

_____________________

____________________

PLEASE FILL THIS SECTION OUT COMPLETELY

SECURITIES:

Are All Splits Included

YES

Dates____________________________

Explanation:____________________________________________________________________________________________________________________

Are All Spinoffs Included

YES

Dates____________________________

Explanation:____________________________________________________________________________________________________________________

Is the issue remitted the same as the issue in the owner’s possession? . . . . . . . . . . . . . . . . .

YES

CERTIFICATION:

I hereby certify that this report was prepared on ________________________and is a true and accurate statement of all unclaimed property held as of the close of the report cycle,

updated for appropriate interest/income/dividends to the date of this report. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to

punishment according to law.

Signature: __________________________________________________________ Title: ______________________________________ Date: ___________________________

FOR OFFICE USE ONLY

Report Status: ________________

Remitted:

Cash

$__________________________

Securities: __________________________

HOLDER ADDED . . . . . . . . . . . . . . . . . . Date: __________________

Employee: _______________________________

REPORT ADDED . . . . . . . . . . . . . . . . . . . Date: __________________

Employee: _______________________________