Form Ufs-1 - Universal Holder Face Sheet
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1State of California—Controller’s Office
Report ID# (Remit Report Only)
UNIVERSAL HOLDER FACE SHEET
Required
(
must be completed and attached with all reports, failure to do so may result in interest assessment)
UFS-1(Rev. 01/15)
Mail to: Office of State Controller Betty T. Yee, Unclaimed Property Division, P.O. Box 942850, Sacramento, CA 94250
Notice Report
Or
Remit Report
Due Before November 1 or
Due Between June 1 and June 15 or
Life Insurance Due Before May 1
Life Insurance Due Between December 1 and December 15
Supplemental Notice Report (
)
Properties not included on the Notice Report cannot be listed on the Remit Report and must be reported on a Supplemental Notice Report
Section A—Holder Information
FEIN
Branch Number
Report As of Date
Check Number / EFT Debit Ref Number (Remit Report Only)
Section B—Holder Contact Information
Holder Name
Street Address
City
State
Zip Code
Country
P.O. Box Number
Contact Name (For report completion)
Title
Phone Number
Extension
E-mail Address
Section C—Property Owner Contact Information
Holder Name
Street Address
P.O. Box Number
City
State
Zip Code
Country
Contact Name
Title
Phone Number
Extension
E-mail Address
Section D—Holder Agent Contact (If Applicable)
Agent Name
Street Address
P.O. Box Number
City
State
Zip Code
Country
Contact Name (For report completion)
Title
Phone Number
Extension
E-mail Address
Section E—Holder CEO/CFO
Name
Title
Address
P.O. Box Number
City
State
Zip Code
Country
Total Reported/Remitted Dollars
Total Reported/Remitted Shares
Section F—Holder Report Totals
Includes Safe Deposit Box
YesNo
*Any Remittance of $20,000.00 or more must be paid by Electronic Funds Transfer (EFT), pursuant to CCP Section 1532
Section G - Holder Business Information
Organization Type:
NAICS Code:
Incorporation State:
Incorporation Date :
/
/
Charter:
Federal
or
State Charter Date:
/ /
Section H– Demutualization Proceeds
This report includes proceeds from the demutualization of an insurance company
Date of Demutualization
CCP Section 1515.5 (a)
CCP Section 1515.5 (b)
CCP Section 1515.5 (c)
Agent Name
Section I– Transfer Agent (If Applicable)
Street Address
P.O. Box Number
City
State
Zip Code
Country
Section J: Verification
Section J - Verification If made by an individual, shall be verified by the individual; if made by a partnership, by a partner; if made by an unincorporated association or
private corporation, by an officer; if made by a public corporation, by its chief fiscal officer or other employee authorized by the holder (CCP Section 1530(e)).
The undersigned,
declares, under penalty of perjury, that, to the best of (his) (her) knowledge and belief, the following sheets
contain a full, true, and complete report of unclaimed property which is presumed unclaimed under the provisions of Part 3, Title 10, Chapter 7, Code of Civil Procedure,
commencing with Section 1500, and Title 2, California Administrative Code, Sections 1150 et seq. The Undersigned also confirms that all properties not listed on the
Remit Report, which were initially included on the Notice Report, were due to contact by the apparent owner, or the property being reactivated or returned to the
rightful owner.
Signature
Title
Date
UFS-1 (Rev 01/15)
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Parent category: Financial