Form Upc-1 - Verification Summary For Unclaimed Property
ADVERTISEMENT
1VERIFICATION SUMMARY FOR UNCLAIMED PROPERTY
INSTRUCTIONS ON REVERSE SIDE
REQUIRED INFORMATION
HOLDER NAME & ADDRESS:
_________________________________________________
______________________________________________________
VERIFICATION FOR PERIOD ENDED _______________________ , 20____
______________________________________________________
STATE OF INCORPORATION ____________________________________
______________________________________________________
DATE OF INCORPORATION _____________________________________
______________________________________________________
PRIMARY BUSINESS ACTIVITY __________________________________
______________________________________________________
FEDERAL IDENTIFICATION # ____________________________________
PLEASE ENTER THE AMOUNT BEING REPORTED FOR EACH PROPERTY TYPE IN THE APPROPRIATE SPACE.
DEPOSIT ACCOUNTS
MISCELLANEOUS PROPERTY TYPES
AC01 CHECKING ACCOUNT/DEMAND DEPOSITS $ ______________
MS01 PAYROLL, WAGES, SALARY
$ ______________
AC02 SAVINGS ACCOUNTS
______________
MS02 COMMISSIONS
______________
AC03 MATURED CD OR SAVINGS CERTIFICATES
______________
MS03 WORKERS COMPENSATION BENEFITS
______________
AC04 CHRISTMAS CLUB FUNDS
______________
MS04 PAYMENT FOR GOODS & SERVICES
______________
AC05 MONEY ON DEPOSIT TO SECURE FUNDS
______________
MS05 CUSTOMER OVERPAYMENT
______________
AC06 SECURITY DEPOSITS
______________
MS06 UNIDENTIFIED REMITTANCES
______________
AC07 UNIDENTIFIED DEPOSITS
______________
MS07 UNREFUNDED OVERCHARGES
______________
AC08 SUSPENSE ACCOUNTS
______________
MS08 ACCOUNTS PAYABLE
______________
AC99 AGGREGATE REPORTING
______________
MS09 CREDIT BALANCE – ACCOUNTS RECEIVABLE ______________
MS10 DISCOUNTS DUE
______________
CHECKS
MS11 REFUNDS DUE
______________
CK01 CASHIER'S CHECK
______________
MS12 UNREDEEMED GIFT CERTIFICATES
______________
CK02 CERTIFIED CHECKS
______________
MS13 UNCLAIMED LOAN COLLATERAL
______________
CK03 REGISTERED CHECKS
______________
MS14 PENSION & PROFIT SHARING
______________
CK04 TREASURER'S CHECKS
______________
MS15 DISSOLUTION OR LIQUIDATION
______________
CK05 DRAFTS
______________
MS16 MISC OUTSTANDING CHECKS
______________
CK06 WARRANTS
______________
MS17 MISC INTANGIBLE PERS PROP
______________
CK07 MONEY ORDERS
______________
MS18 SUSPENSE LIABILITES
______________
CK08 TRAVELER'S CHECKS
______________
MS99 AGGREGATE MISC PROPERTY
______________
CK09 FOREIGN EXCHANGE CHECKS
______________
SECURITY RELATED
CK10 EXPENSE CHECK
______________
CK11 PENSION CHECKS
______________
SC01 DIVIDENDS
______________
CK12 CREDIT CHECKS OR MEMOS
______________
SC02 INTEREST (BOND COUPONS)
______________
CK13 VENDOR CHECKS
______________
SC03 PRINCIPAL PAYENTS
______________
CK14 CHECKS WRITTEN OFF TO INCOME
______________
SC04 EQUITY PAYMENTS
______________
CK15 OTHER OUTSTANDING OFFICIAL CHECKS
______________
SC05 PROFITS
______________
CK16 CD INTEREST CHECKS
______________
SC06 FUNDS PAID TO PURCHASE SHARES
______________
CK99
50
______________
SC07 FUNDS FOR STOCK AND BONDS
______________
AGGREGATE UNCASHED CHECKS-LESS THAN $
SC08 SHARES OF STOCK
______________
(RETURNED BY POST OFFICE)
COURT RELATED
SC09 CASH FOR FRACTIONAL SHARES
______________
CT01 ESCROW FUNDS
______________
SC10 UNEXCHANGED STOCK OF SUCCESSOR CORP _____________
CT02 CONDEMNATION AWARDS
______________
SC11 OTHER CERT OF OWNERSHIP
______________
CT03 MISSING HEIRS' FUNDS
______________
SC12 UNDERLYING SHARES OR OUTSTANDING CERT ____________
CT04 SUSPENSE ACCOUNTS
______________
SC13 FUNDS FOR LIQUIDATION
______________
CT05 OTHER COURT DEPOSITS
______________
SC14 DEBENTURES
______________
CT99 AGGREGATE COURT DEPOSITS
______________
SC15 US GOVT SECURITIES
______________
INSURANCE REALTED
SC16 MUTUAL FUND SHARES
______________
IN01
_____________
INDIVIDUAL POLICY BENEFIT OR CLAIM PAYMENTS
SC17 WARRANTS (RIGHTS)
______________
IN02
GROUP POLICY BENEFIT OR CLAIM PAYMENTS _____________
SC18 MATURED BOND PRINCIPAL
______________
IN03
PROCEEDS DUE BENEFICIARY
______________
SC19 DIVIDEND REINVESTMENT PLANS
______________
IN04
PROCEEDS-MATURED POLICIES,
SC20 CREDIT BALANCES
______________
ENDOWMENTS, ANNUITIES
______________
SC21 COMMON STOCK
______________
IN05
PREMIUM REFUNDS
______________
SC22 CONVERTIBLE SECURITIES
______________
IN06
UNIDENTIFIED REMITTANCES
______________
SC23 PREFERRED SECURITIES
______________
IN07
OTHER AMOUNTS DUE UNDER POLICY
______________
SC24 FIXED INCOME SECURITY
______________
IN08
AGENT CREDIT BALANCES
______________
SC25 REAL ESTATE - BASED SECURITY
______________
IN99
AGGREGATE INSURANCE PROPERTY
______________
SC99 AGGREGATE SECURITY RELATED
______________
MINERAL PROCEEDS
TANGIBLE PROPERTY
MI01
NET REVENUE INTEREST
______________
SD01 SAFE DEPOSIT BOX CONTENTS
______________
MI02
ROYALTIES
______________
SD02 OTHER SAFE KEEPING
______________
MI03
OVERRIDING ROYALTIES
______________
SD03 OTHER TANGIBLE PROPERTY
______________
MI04
PRODUCTION PAYMENTS
______________
RELATED TRUST
MI05
WORKING INTEREST
______________
TR01 PAYING AGENT ACCOUNT
______________
MI06
BONUSES
______________
TR02 UNDELIVERED/UNCASHED DIVIDENDS
______________
MI07
DELAY RENTALS
______________
TR03 FUNDS HELD IN FIDICUIARY CAPACITY
______________
MI08
SHUT-IN ROYALTIES
______________
TR04 ESCROW ACCOUNTS
______________
MI09
MINIMUM ROYALTIES
______________
TR05 TRUST VOUCHERS
______________
MI99
AGGREGATE MINERAL PROCEEDS
______________
TR99 AGGREGATE TRUST RELATIONS
______________
UTILITY RELATED
HEALTH SAVINGS PLANS
UT01 UTILITY DEPOSITS
______________
HS01 HEALTH SAVINGS ACCOUNT
______________
UT02 MEMBERSHIP FEES
______________
HS02 HEALTH SAVINGS ACCOUNT INVESTMENT
______________
UT03 REFUNDS OR REBATES
______________
OTHER
UT04 CAPITAL CREDIT DISTRIBUTIONS
______________
ZZZZ PROPERTIES NOT IDENTIFIED
______________
UT99 AGGREGATE UTILITY PROPERTY
______________
I DECLARE THAT THIS REPORT, INCLUDING ACCOMPANYING STATEMENTS, HAS BEEN EXAMINED BY ME; THAT I AM DULY AUTHORIZED BY THE HOLDER
HEREIN TO EXECUTE THIS REPORT; AND THAT I BELIEVE SAID REPORT IS TRUE, CORRECT AND COMPLETE FOR THE STATED PERIOD.
SIGNATURE ____________________________ DATE ___________
TELEPHONE NUMBER (
)_______________________________
TITLE___________________________________________________
ADDRESS ____________________________________________
ANNUAL REPORT OF_____PAGES TOTALING $ _______________
____________________________________________
1 Public Use
2 UPD Use Only
UPC 1 –4/2011
THIS FORM MUST ACCOMPANY THE
REPORT OF UNCLAIMED PROPERTY
CONTACT PERSON_____________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business