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AP1 Unclaimed Property Holders Report (DOC) by huangyuarong

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									                                                                                                              For State Use Only
                                                                                                        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:



                                                                        2ee63dfa-de8f-4f49-84d4-a4da96705500.doc Revised 4/22/2012
                                                              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
                                                                  2ee63dfa-de8f-4f49-84d4-a4da96705500.doc Revised 4/22/2012

								
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