Form Up-1 - Report Of Unclaimed Property Verification And Checklist Page 2
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2List the names and last known address of all previous holders of the property if you are a successor. If you have changed your name during the time period in which you have
held the property, list the prior name (s)
Date of Change
Tax Identification Number
Name of Business (Previous Holder)
Street Address
City
State, Postal Code
Please indicate which of the following best describe the primary activity
State of Incorporation
Date of Incorporation
of your company (select one)
Life Insurance Company
Did you file an unclaimed Property Report last year Yes
Please explain, if No
Person to contact
Telephone Number
Email-Address
AFFIDAVIT
I,
, being first duty sworn on oath depose and state that I have caused to be prepared and have examined this report
consisting 0f
pages totaling $
as to property presumed abandoned under the DC Unclaimed Property Law for the
year ending as stated; that I am duty authorized by the holder herein to execute this report; and I believe that said report is true,
correct and complete as of said date, excepting for such property as has since ceased to be abandoned. Includes with this report is a
cash remittance totaling $
Sworn to (or affirmed) and Subscribed before me this
_________________ day of_________________, 20_____
___________________________________________
Signature of Officer, Owner, etc.
____________________________________
___________________________________________
Notary Public
Title of person signing
My Commission expires______________________________________________
This report must be signed by an authorized person and acknowledged before a notary public. If a partnership, it must be signed by a partner; if an
unincorporated association or private corporation by an officer.
Mail Reports to: Office of Finance and Treasury, Unclaimed Property Division
th
1101 4
Street S.W. Suite 800 W, Washington DC 20024
202-442-8181 Telephone
Page 2 of 2
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Parent category: Financial