Form Ap-1 Neg - Negative Reporting Form For Abandoned And Unclaimed Property Page 2
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2_______________________________________________________________________ has policies and
(name of company)
procedures in place to account for dormant property and eventually report unclaimed property to the
Commonwealth of Pennsylvania in accordance with 72 P.S. § 1301 et.seq.
___________________________________________________________________ understands that
(name of company)
unreported and/or undelivered property is subject to 12% interest in accordance with 72 P.S. §§ 1301.24, and
other penalties as provided for in statute, including but not limited to 72 P.S. § 1301.25 (relating to penalties).
The undersigned herby 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
____________________________________________________________
Print Name
____________________________________________________________
Title
_______________________________________
Date
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