UP-1N (Rev. 06/2013)
ZERO / NEGATIVE
HOLDER REPORT FORM
2013
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:
4. NAME OF CONTACT PERSON
5. TELEPHONE
6. E-MAIL ADDRESS
(
)
8. STATE OF INCORPORATION
7. DATE OF INCORPORATION
9. PRIMARY BUSINESS ACTIVITY
13. TOTAL ASSETS
10. NO. OF EMPLOYESS
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 as of said date to the best of my knowledge.
Signature of Responsible Officer
Printed or Typed Name Responsible Officer
Title of Responsible Officer/Agent
Date