Form Ap-1 Neg - Negative Reporting Form For Abandoned And Unclaimed Property
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AP- 1 Neg
NEGATIVE REPORTING FORM FOR ABANDONED AND UNCLAIMED PROPERTY
TREASURY USE ONLY
Robert M. McCord
Report Year _____________________
Treasurer
Prepared By _____________________
COMPANY INFORMATION:
Company Name ________________________________________________________________________
Federal ID Number (FEIN) _______________________________________________________________
Address 1 ____________________________________________________________________________
Address 2 ____________________________________________________________________________
Address 3 ____________________________________________________________________________
City ________________________________________
State _______
Zip Code
_________________
County ______________________________
State of Incorporation _____________________________
Industry Type (scroll down in box and click on type) ___________________________________________
Agriculture, Forestry, Fishing
Mining & Oil/Gas
Assets $_____________________ Annual Sales $ ___________________
Number of Employees ____________________
CONTACT INFORMATION:
Primary Contact Name
_________________________________________________________________
Address 1 (If different from above _________________________________________________________
Address 2 ____________________________________________________________________________
Address 3 ____________________________________________________________________________
City ________________________________________
State _______
Zip Code
_________________
County ________________________ Phone (_____)_________________ Extension
______________
Fax (_____)___________________
Email _________________________________________________
HOLDER VERIFICATION:
The Pennsylvania Treasury, Bureau of Unclaimed Property requires the signature of the Chief Financial
Officer or other corporate officer responsible for the financial operations of the company.
The undersigned hereby verifies that an annual review of the books and records of
______________________________________________________________________ has been performed.
(name of company)
As a result of this review, we can definitively state that this company is not in possession of any unclaimed
property that is due and reportable to the Commonwealth of Pennsylvania.
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