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CHECK AMOUNT ___________
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF THE TREASURY CHECK # __________________
Division of Unclaimed Property
P.O. Box 2478 DEPOSIT DATE _____________
Richmond, VA 23218 INITIALS _______________
(804) 225-2393 Fax (804) 786-4653 INTEREST PAYMENT AMOUNT
Toll Free 1-800-468-1088 $__________________________
AP1 FORM FOR REPORT OF UNCLAIMED PROPERTY
Holder Name: Holder Number:
Address:
City: State: Zip Code:
1. If the address above is incorrect, please correct here: 2. Contact Person:
Name: Title:
Address: Department:
City: State: Zip Code: Telephone Number:
3. Please provide an e-mail address: Fax Number:
ABOUT THIS BUSINESS ENTITY:
4. Federal Employer Identification Number 5. Standard Industry Code
6. State of Incorporation (or locality where business license is filed if not incorporated)
7. Date of Incorporation 8. Primary Business Activity
9. Annual Gross Income $ Assets $ # of Employees
ABOUT THIS REPORT:
10. Date(s) Due Diligence was Performed
11. Report Year . Type of report is REGULAR AUDIT NEGATIVE (optional) OTHER
12. This report has ONE of the following media attached to report the property details:
REPORT UPLOADED TO WEBSITE DISKETTE/CD HARD COPY-PAPER, CONSISTING OF PAGES
13. This is the first time this business entity has filed an Unclaimed Property Report YES NO
14. Property types on this report include: CASH SECURITIES MUTUAL FUNDS TANGIBLE PROPERTY
IMPORTANT NOTICE: Your remittance must accompany this report and an authorized representative of your business
must complete the certification that follows. Please complete the summary information on the reverse of this page, and mail
your report and remittance to the address at the top of this form. Pursuant to §55-210.26:1 of the Code of Virginia, interest
and penalties may be imposed for failure to report and remit as required.
I, , CERTIFY THAT I HAVE CAUSED TO BE PREPARED AND I 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. THIS REPORT TOTALS #
PROPERTIES FOR $ AND # SHARES.
SIGNATURE:
TITLE: DATE:
17bb88bc-25c3-47ef-be18-571a0b7ca848.doc Revised 4/19/2012
MISSING HEIRS’ FUNDS
CASH PROPERTY CT03
CT04 SUSPENSE ACCOUNTS
CT05 OTHER COURT DEPOSITS TANGIBLE PROPERTY
ACCOUNT BALANCES DUE CT07 EVIDENCE MONEY
CT08 GENERAL RECEIVER ACCOUNTS (1 year) SAFE DEPOSIT BOXES & SAFEKEEPING
AC01 CHECKING ACCOUNTS CT09 COURT ORDERED REFUNDS (1 year)
AC02 SAVINGS ACCOUNTS CT10 PERSONAL PROPERTY TAX OVERPAYMENT
AC03 MATURED CD OR SAVINGS CERTIFICATE SD01 SAFE DEPOSIT BOX CONTENTS
CT11 REAL ESTATE TAX OVERPAYMENT SD02 OTHER SAFEKEEPING
AC04 CHRISTMAS CLUB FUNDS CT12 COURT HELD ACCOUNTS
AC05 MONEY ON DEPOSIT TO SECURE FUND SD03 OTHER TANGIBLE PROPERTY
CT13 BONDS
AC06 SECURITY DEPOSIT CT14 ESTATE ACCOUNTS
AC07 UNIDENTIFIED DEPOSITS CT15 LITIGATIONS TANGIBLE PROPERTY SUMMARY:
AC08 SUSPENSE ACCOUNTS CT16 RESTITUTIONS
AC09 SHARE ACCOUNTS CT99 AGGREGATE COURT DEPOSITS <$100
AC21 MISCELLANEOUS DEPOSITS
TOTAL ITEM COUNT: ________________________
AC99 AGGREGATE ACCOUNT BALANCES <$100 INSURANCE
CS01 EDUCATIONAL SVGS ACCT (CSP, COVERDALE) TOTAL # OF OWNERS: _______________________
HS01 HEALTH SAVINGS ACCT IN01 INDIVIDUAL POLICY BENEFITS OR CLAIMS PD
HS02 HEALTH SAVGS ACCT INVESTMENT IN02 GROUP POLICY BENEFITS OR CLAIMS PAID
IR01 IRA TRADITIONAL (SEP,SARSEP,SIMPLE) IN03 PROCEEDS DUE BENEFICIARIES
IR05 ROTH IRA IN04 PROCEEDS FROM MATURED POLICIES, SECURITY PROPERTY
ENDOWMENTS
UNCASHED CHECKS IN05 PREMIUM REFUNDS SECURITIES
IN06 UNIDENTIFIED REMITTANCES
CK01 CASHIER’S CHECKS IN07 OTHER AMOUNTS DUE UNDER POLICY TERMS SC01 DIVIDENDS
CK02 CERTIFIED CHECKS IN08 AGENT CREDIT BALANCES SC02 INTEREST (BOND COUPONS)
CK03 REGISTERED CHECKS IN09 ANNUITIES SC03 PRINCIPAL PAYMENTS
CK04 TREASURER’S CHECKS -IN10 DEMUTUALIZATION CASH SC04 EQUITY PAYMENTS
CK05 DRAFTS IN99 AGGREGATE INSURANCE PROPERTY <$100 SC05 PROFITS
CK06 WARRANTS
SC06 FUNDS PAID TO PURCHASE SHARES
CK07 MONEY ORDERS (7 years) TRUST, INVESTMENT AND ESCROW ACCOUNTS SC07 FUNDS FOR STOCKS AND BONDS
CK08 TRAVELER’S CHECKS (15 years)
SC08 SHARES OF STOCK (RETURNED BY POST
CK09 FOREIGN EXCHANGE CHECKS TR01 PAYING AGENT ACCOUNTS OFFICE)
CK10 EXPENSE CHECKS TR02 UNDELIVERED OR UNCASHED DIVIDENDS SC09 CASH FOR FRACTIONAL SHARES
CK11 PENSION CHECKS TR03 FUNDS HELD IN FIDUCIARY CAPACITY SC10 UNEXCHANGED STOCK OF SUCCESSOR CORP
CK12 CREDIT CHECKS OR MEMOS TR04 ESCROW ACCOUNTS SC11 OTHER CERTIFICATES OF OWNERSHIP
CK13 VENDOR CHECKS TR05 TRUST VOUCHERS SC12 UNDERLYING SHARES OR OTHER
CK14 CHECKS WRITTEN OFF TO INCOME TR06 ENDOWMENT FUNDS STANDING CERTIFICATES
CK15 OTHER OUTSTANDING OFFICIAL CHECKS TR99 AGGREGATE TRUST PROPERTY <$100 SC13 FUNDS FOR LIQUIDATION/REDEMPTION OF
CK16 CD INTEREST CHECKS
UNSURRENDERED STOCK OR BONDS
CK99 AGGREGATE UNCASHED CHECKS <$100 UTILITIES SC14 DEBENTURES
SC15 US GOVT SECURITIES
MISCELLANEOUS CHECKS UT01 UTILITY DEPOSITS (1 year upon service termination) SC16 MUTUAL FUND SHARES
UT02 MEMBERSHIP FEES SC17 WARRANTS (RIGHTS)
MS01 WAGES, PAYROLL, SALARY (1 year) UT03 REFUNDS OR REBATES SC18 MATURED BOND PRINCIPAL
MS02 COMMISSIONS (1 year) UT04 CAPITAL CREDIT DISTRIBUTIONS SC19 DIVIDEND REINVESTMENT PLANS
MS03 WORKERS’ COMPENSATION BENEFITS UT99 AGGREGATE UTILITY PROPERTY <$100 SC20 CREDIT BALANCES
MS04 PAYMENT FOR GOODS & SERVICES
SC21 LIQUIDATED MUTUAL FUND SHARES
MS05 CUSTOMER OVERPAYMENTS MINERAL PROCEEDS & MINERAL INTERESTS SC99 AGGREGATE SECURITY RELATED CASH <$100
MS06 UNIDENTIFIED REMITTANCES
-IR02 MUTUAL FUNDS – IRA
MS07 UNREFUNDED OVERCHARGES MI01 NET REVENUE INTEREST -IR03 SECURITIES – IRA
MS08 ACCOUNTS PAYABLE MI02 ROYALTIES -IR05 MUTUAL FUNDS – ROTH IRA
MS09 CREDIT BALANCES – A/R MI03 OVERRIDING ROYALTIES -IR07 SECURITIES – ROTH IRA
MS10 DISCOUNTS DUE MI04 PRODUCTION PAYMENTS -CS02 MUTUAL FUNDS – EDUCATIONAL SVGS ACCT
MS11 REFUNDS DUE MI05 WORKING INTEREST -CS03 SECURITIES – EDUCATIONAL SVGS ACCT
MS12 UNREDEEMED GIFT CERTIFICATES MI06 BONUSES
MS13 UNCLAIMED LOAN COLLATERAL MI07 DELAY RENTALS
MS14 PENSION & PROFIT SHARING PLANS (IRA , KEOGH) MI08 SHUT-IN ROYALTIES
MS15 DISSOLUTION OR LIQUIDATION (1 year) MI09 MINIMUM ROYALTIES SECURITY PROPERTY SUMMARY:
MS16 MISC OUTSTANDING CHECKS MI99 AGGREGATE MINERAL INTERESTS <$100
MS17 MISC INTANGIBLE PROPERTY
MS18 SUSPENSE LIABILITIES
TOTAL SHARES REMITTED:__________________
MS19 OTHER CASH
CASH PROPERTY SUMMARY:
MS21 EMPLOYEE BENEFIT TRUST DISTRBTNS (10 years) TOTAL # OF ITEMS:_________________________
MS99 AGGREGATE MISC PROPERTY <$100 TOTAL CASH REMITTED:______________________
COURT & LOCALITY FUNDS
TOTAL # OF ITEMS: __________________________
CT01 ESCROW FUNDS
CT02 CONDEMNATION AWARDS
17bb88bc-25c3-47ef-be18-571a0b7ca848.doc Revised 4/19/2012
