Form Ap-1 - Unclaimed Property Form

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Division of Unclaimed Property 
AP‐1
P O Box 2478, Richmond, VA  23218‐2478 
 
                                            PHONE (804) 225‐2393        FAX (804) 786‐4653      TOLL FREE 1‐800‐468‐1088 
 
Holder Number_____________________________________________________________________________ 
Holder Name_______________________________________________________________________________ 
Address___________________________________________________________________________________ 
City___________________________________State ____________________Zip________________________ 
Federal Tax ID______________________________________________________________________________ 
Contact Name______________________________________________________________________________ 
Telephone Number__________________________________________________________________________ 
Fax Number________________________________________________________________________________ 
E‐Mail address______________________________________________________________________________ 
State of Incorporation________________________________ State of Headquarters (if different)___________ 
Date of Incorporation_________________________________________________________________________ 
SIC/NAICS code______________________________________________________________________________ 
Number of Employees________________________________________________________________________ 
Total Assets_________________________________________________________________________________ 
Report Year_____________ First Time Report?  __ Yes  __ No 
 
 
Type of Report: (check one) 
Reported Total Amounts:  
Total shares remitted:  
Regular (Annual) 
 
 
Audit 
_____________________Cash  
__________via DTC 
Voluntary Compl. 
 
 
 __________via DRP statement  
Negative 
___________________Security Shares
 
Report Media: (check one)  
 
 
__________via House Account           
Hardcopy (Paper) 
______________# of Tangible Accounts 
                      statement 
CD   
 
Uploaded (NAUPA file) 
Remittance:  
check 
________________check #   ___________________Amount 
Make Checks Payable To: 
check 
________________check #   ___________________Amount 
Treasurer of Virginia 
wire 
________________wire ID #  ___________________Amount  
 
ACH   
________________ACH #  
___________________Amount 
 
ATA / REDI________________   ID #  
___________________Amount
 
 
‐I  CERTIFY  THAT  I  HAVE  CAUSED  TO  BE  PREPARED  AND  HAVE  EXAMINED  THIS  REPORT  AS  TO  PROPERTY  PRESUMED 
ABANDONED  UNDER  THE  VIRGINIA  UNCLAIMED  PROPERTY  LAW  FOR  THE  YEAR  ENDING  AS  STATED,  THAT  I  AM  DULY 
AUTHORIZED TO EXECUTE THIS VERIFICATION BY THE HOLDER AND BY LAW AND THAT 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.   
 
‐I CERTIFY THAT DUE DILIGENCE WAS PERFORMED ON THE FOLLOWING DATES 
 
 FROM______________________________TO____________________________ 
 
SIGNATURE ________________________________________________Print____________________________________ 
 
TITLE ____________________________________________________________ 
 
DATE ________________________________ 

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