Form Ap-1 - Submission Of All Unclaimed Property Reports

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AP-1
Division of Unclaimed Property
P O Box 2478, Richmond, VA 23218-2478
PHONE (804) 225-2393
FAX (804) 786-4653
TOLL FREE 1-800-468-1088
Holder Number_____________________________________________________________________________
Holder Name_______________________________________________________________________________
Address___________________________________________________________________________________
City___________________________________State ____________________Zip________________________
Federal Tax ID______________________________________________________________________________
Contact Name______________________________________________________________________________
Telephone Number__________________________________________________________________________
Fax Number________________________________________________________________________________
E-Mail address______________________________________________________________________________
State of Incorporation________________________________________________________________________
Date of Incorporation_________________________________________________________________________
SIC/NAICS code______________________________________________________________________________
Number of Employees________________________________________________________________________
Total Assets_________________________________________________________________________________
Report Year_____________
I,
Type of Report: (check one)
___________________________________________
,
Regular (Annual)
CERTIFY THAT I HAVE CAUSED TO BE PREPARED AND HAVE
Audit
EXAMINED THIS REPORT AS TO PROPERTY PRESUMED ABANDONED
Negative
UNDER THE VIRGINIA UNCLAIMED PROPERTY LAW FOR THE YEAR
Special
ENDING AS STATED, THAT I AM DULY AUTHORIZED TO EXECUTE
THIS VERIFICATION BY THE HOLDER AND BY LAW AND THAT I
Report Media: (check one)
BELIEVE THAT SAID REPORT IS TRUE, CORRECT, AND COMPLETE AS
paper/hardcopy
OF SAID DATE, EXCEPTING FOR SUCH PROPERTY AS HAS SINCE
CD
CEASED TO BE ABANDONED. I CERTIFY THAT DUE DILIGENCE WAS
Uploaded file to website
PERFORMED ON THE FOLLOWING DATES
______________________________TO____________________________
Reported Total Amounts:
(_____________________cash)
SIGNATURE
(___________________security shares)
_________________________________________________________
(______________#of tangible accounts)
TITLE
Total shares remitted:
____________________________________________________________
__________via DTC;
__________via DRP statement;
DATE ________________________________
__________via inhouse statement
Cash Remitted by:
check
___________check #;
___________________Amount
check
___________check #;
___________________Amount
check
___________check #;
___________________Amount
wire
_______________wire ID #; ___________________Amount
ACH
_________________ACH #; ___________________Amount
IAT
________________IAT #;
___________________Amount

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