Fillable AP- 1 REPORT OF ABANDONED AND UNCLAIMED PROPERTY

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AP- 1 REPORT OF ABANDONED AND UNCLAIMED PROPERTY

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The AP- 1 REPORT OF ABANDONED AND UNCLAIMED PROPERTY form is 1 page long and contains:

  • 1 signature
  • 36 check-boxes
  • 22 other fields

Country of origin: US
File type: PDF

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HOLDER INFORMATION:
Holder’s Name ______________________________________________________________________________
Federal EIN Number __________________________________________________________________________
Contact Name ___________________________ Phone _____________ Email ________________________
Address 1 __________________________________________________________________________________
City ____________________________________________ State _______ Zip Code _____________________
County ___________________________ State of Incorporation _________________ Report Year __________
Is this the rst me your organizaon has led an abandoned and unclaimed property report to the Commonwealth of Pennsylvania?
YES ____ NO ____
Have you ever reported under another company name? YES ____ NO ____
If so, under what company name? _________________________________ Federal EIN # ____________
Please fill in the blanks below for a positive report. Report should be signed by Company President, Chief Executive Officer or
Chief Financial Officer. (For negative reports, please use the ‘AP-1 Neg’ form.)
I have prepared and examined this AP-1 report consisting of ___________ pages totaling $___________________ as to property
presumed abandoned under the Pennsylvania Disposition of Abandoned and Unclaimed Property Act for the year ended as
stated. I verify this report is accurate and complete to the best of my knowledge and belief as of said date.
I certify that due diligence was performed in accordance with 72 P.S. §1301.10a, Notice Given to Holders.
Please check if your payment is a Wire Transfer.
Please check if your Holder Report/Remittance contains any property related to retirement accounts (e.g. traditional IRAs,
simplified employee pension plans, etc.)
I certify that any retirement accounts reported adhere to Treasury’s Policy Guidance
(https://www.patreasury.gov/pdf/unclaimed-property/Policy-Guidance-2016.pdf)
HOLDER VERIFICATION: The undersigned hereby verifies that the statements set forth in this holder report are true, and
acknowledges that any false statements contained therein are subject to the penalties of 18 Pa. C.S.A. § 4904 (relating to
unsworn falsification to authorities).
Print Name Title
AP- 1
Overnight (UPS, FedEx, Post Office) and all other Courier deliveries
LOCKBOX SERVICES (783473)
COMMONWEALTH OF PENN UNCLAIMED PROPERTY
MAC Y1372-045
401 MARKET STREET
PHILADELPHIA, PA 19106
Industry Type: (check box)
__ Agriculture, Forestry, Fishing
__ Mining & Oil/Gas
__ Ulies
__ Construcon
__ Wholesale Trade
__ Newspapers & TV Broadcasng
__ Finance & Insurance
__ Other Services (Except Public)
__ Professional & Scientific
__ Management of Companies
__ Administrative & Support
__ Educational Services
__ Health Care & Social Assistance
__ Arts, Entertainment & Recreation
__ Accommodation & Food Service
__ County
__ School District
__ Manufacturing
__ Retail
__ Information Technology
__ Municipal Authorities
__ Consulting
__ Trucking
__ Transportation
__ Police Departments
__ Correctional Institutions
__ Other State Government Agencies
__ Finance
__ Insurance
__ General
COMMONWEALTH OF PENN
UNCLAIMED PROPERTY
P O BOX 783473
PHILADELPHIA, PA 19178- 3473
Signature Date
REPORT OF ABANDONED AND UNCLAIMED PROPERTY VERIFICATION AND CHECKLIST
Report for Period Ended December 31,
Mail to: Post Office – standard first class and certified mail
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AP- 1 REPORT OF ABANDONED AND UNCLAIMED PROPERTY

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Completed 3 February 2022

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