Form Up-1n - Zero/negative Holder Report Form - 2011

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UP-1N (Rev. 01/12)
ZERO/NEGATIVE
HOLDER REPORT FORM
2011
Negative reports are required!
ARE YOU A 1ST TIME FILER? Y [ ] N [ ]
HOLDER INFORMATION
1. FEDERAL EMPLOYER ID#
2. HOLDER (Business Name)
ADDRESS
CITY, STATE, ZIP CODE
3. IS THIS REPORT BEING PREPARED BY AN AGENT ON BEHALF OF THE HOLDER?
Y [
]
N [
]
IF YES, FURNISH AGENT NAME
AND ADDRESS:
5. TELEPHONE
4. NAME OF CONTACT PERSON
6. E-MAIL ADDRESS
(
)
8. STATE OF INCORPORATION
7. DATE OF INCORPORATION
9. PRIMARY BUSINESS ACTIVITY
10. NO. OF EMPLOYESS
13. TOTAL ASSETS
11. ANNUAL SALES/PREMIUMS
12. PREMIUMS WRITTEN IN GA
REPORT INFORMATION
INTANGIBLE PROPERTY - (Outstanding Checks)
14a. Total accounts $50.00 or more
0
14b. Dollar Value $
0
14c. Total accounts less than $50.00
0
14d. Dollar Value $
0
14e. Report Total $
0
OTHER PROPERTY (Safe deposit boxes, stocks, mutual funds)
14f. Number of shares of stock or mutual fund shares
0
14g. Number of safe deposit boxes/safekeeping items
0
VERIFICATION STATEMENT
I,
certify that I have caused to be prepared and have examined this report
totaling $
0
as to property presumed abandoned under the “Disposition of Unclaimed Property Act” for the
year ended as stated, that I am duly authorized to execute this verification by the holder and that I believe said report to be
true, correct and complete.
Signature of Responsible Officer
Printed or Typed Name Responsible Officer
Date
Title of Responsible Officer/Agent

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