FORM UP-1 SUMMARY REPORT
FOR TREASURY USE ONLY
REPORTS AND REMITTANCE are due November 1
of each reporting year for the property listed that is
unclaimed as of the preceding June 30th:
STATE OF MISSISSIPPI
Lynn Fitch
UNCLAIMED PROPERTY REPORT
State Treasurer
REPORT YEAR ___________ Date of this report______________ Federal ID #________________________
Name of Holder:
Contact Person
_______________________________________________________
_______________________________________________________________
Mailing Address
Phone
Fax
_______________________________________________________
_______________________________________________________________
City, State, Zip
E-Mail address
Type of Business
_______________________________________________________
_______________________________________________________________
Years qualified to do business in Mississippi
In compliance with the Mississippi Uniform Disposition of Unclaimed Property Act the above holder hereby reports the following property subject to the Act for the period ending June 30:
_______________________________________________________
Funds held and owing which have remained unclaimed and unpaid and presumed abandoned, as reported in detail on the attached
$ ________________________
forms, amounting in total to
AFFIDAVIT
MAIL REPORT & CHECK
State of _______________________ County/City of ______________________________
PAYABLE TO:
I, ___________________________________, ___________________________________
State Treasurer of Mississippi
(Type in name of officer, owner, etc., signing)
(Type in title of person signing)
of the company, or holder, for which this report is made, being duly sworn (or affirmed) according to law do depose and
Unclaimed Property Division
say that this report is true and contains all facts required by law to be reported.
P. O. Box 138
Jackson, MS
39205-0138
______________________________________________________
Signature of officer, owner, etc.
Sworn to (or affirmed) and subscribed before me this _________day of _____________________, _________
FILE THIS COPY ON OR BEFORE
___________________________________
NOVEMBER 1 WITH FORM UP-2
(Notary Public)