Fill - INSTRUCTIONS FOR HOLDER REQUEST FOR REIMBURSEMENT

INSTRUCTIONS FOR HOLDER REQUEST FOR REIMBURSEMENT

PURPOSE: A holder of abandoned and unclaimed property must complete this form to seek

reimbursement from the Treasury Department for funds or shares which were paid by the

holder to the Treasury Department and for which the righul owner (or his representave)

has submied a claim to the holder for the monies or shares.

INSTRUCTIONS:

1) Complete the form as outlined below.

2) If claim is greater than $10,000, provide signature idencaon in the form of a drivers

license or signed work idencaon card or badge.

3) Provide proof of payment. No reimbursement will be honored without proof of

payment in the form of a legible, readable copy of the cancelled check or reissued stock

cercate, or documentaon that the customer’s account has in fact been reacvated,

including the date of said reacvaon.

COMPLETION OF FORM: All informaon must be accurate and complete. As long as the report year is listed on each

line, mulple owners may be listed on one AP-5 form. An original form must be submied;

no photocopies will be accepted.

Part I. Holder Informaon: Company Name, address to send reimbursement check,

telephone number and EIN (Employer Idencaon Number) of the holder.

Part II. Claim Informaon: Enter all data necessary to idenfy property for which the holder is

seeking reimbursement. The idencaon data entered on this form must be idencal

to the informaon included on the Report of Abandoned and Unclaimed Property

(AP-2) submied to the Treasury Department. The basic informaon data includes:

1) Report Year.

2) Property Code - the two digit code for the property claimed as dened on the

Summary Sheet of Reported Items (AP-3) or Property Codes (AP-3A).

3) Account/Reference/Check/Number - the idencaon number for the property

which was entered in Column 1 of the AP-2.

4) If the property was reported in the aggregate, specify the aggregate total.

5) Owner(s) Name and Address - the full name(s) and address(es) of the owner(s)

as shown on the AP-2. If “unknown” at me of report, provide name and

current address on form.

6) Claimant(s) Name and Address - the full name(s) and address(es) of the

person(s) who led the claim if dierent than the owner.

7) Date Paid to Claimant or Date Stock Reissued - the date the claim was paid to

the owner (or his representave) or when the account was reacvated by the

holder, or when the stock cercate was reissued.

8) Amount - the dollar amount or number of shares originally transmied by the

holder to the Treasury Department.

9) Total Amount (all pages); Total Number of Shares (all pages) - the amount/number

of shares expected to be reimbursed to the holder by the Treasury Department.

Part III. Holder Cercaon: This notarized statement must be completed before Treasury

will process the request for reimbursement and make payment. Proof that the

claimant was paid and entled to the property must be submied with each and

every holder request for reimbursement. Signature must be of a corporate ocer.

INTEREST: The Treasury Department shall pay interest at the prevailing rate for overpayments pursuant

to secon 806.1 of the Fiscal Code. 72 P.S. Secon 1301.14.

AP-5 INSTRUCTIONS

EIN NUMBER

NAME OF HOLDER

STREET ADDRESS

CITY STATE ZIP CODE

CONTACT PERSON TELEPHONE EXT

HOLDER REQUEST FOR REIMBURSEMENT For funds paid to the Department

PAGE 1 OF 3

PART I HOLDER INFORMATION: (see instructions for claim completion)

PART II CLAIM INFORMATION:

(Please print or type)

TREASURY USE ONLY:

Property ID Number__________________________________

TREASURY USE ONLY:

Property ID Number__________________________________

REPORT YEAR

PROPERTY CODE

ACCOUNT / REFERENCE NUMBER / CHECK NUMBER

IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL

REPORTED OWNER(S) NAME (exactly as indicated on report)

CLAIMANT(S) NAME

CLAIMANT(S) ADDRESS: STREET ADDRESS

CITY STATE ZIP CODE

DATE PAID TO CLAIMANT OR DATE STOCK REISSUED

AMOUNT NUMBER OF SHARES

REPORT YEAR

PROPERTY CODE

ACCOUNT / REFERENCE NUMBER / CHECK NUMBER

IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL

REPORTED OWNER(S) NAME (exactly as indicated on report)

CLAIMANT(S) NAME

CLAIMANT(S) ADDRESS: STREET ADDRESS

CITY STATE ZIP CODE

DATE PAID TO CLAIMANT OR DATE STOCK REISSUED

AMOUNT NUMBER OF SHARES

Claim Number ________________________

Date Received ________________________

Holder EIN ____________________________

Prepared By ___________________________

TREASURY USE ONLY:

(2-10)

AP- 5

PART II CLAIM INFORMATION: (CONTINUED)

PAGE 2 OF 3

TREASURY USE ONLY:

Property ID Number__________________________________

TREASURY USE ONLY:

Property ID Number__________________________________

TREASURY USE ONLY:

Property ID Number__________________________________

REPORT YEAR

PROPERTY CODE

ACCOUNT / REFERENCE NUMBER / CHECK NUMBER

IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL

REPORTED OWNER(S) NAME (exactly as indicated on report)

CLAIMANT(S) NAME

CLAIMANT(S) ADDRESS: STREET ADDRESS

CITY STATE ZIP CODE

DATE PAID TO CLAIMANT OR DATE STOCK REISSUED

AMOUNT NUMBER OF SHARES

REPORT YEAR

PROPERTY CODE

ACCOUNT / REFERENCE NUMBER / CHECK NUMBER

IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL

REPORTED OWNER(S) NAME (exactly as indicated on report)

CLAIMANT(S) NAME

CLAIMANT(S) ADDRESS: STREET ADDRESS

CITY STATE ZIP CODE

DATE PAID TO CLAIMANT OR DATE STOCK REISSUED

AMOUNT NUMBER OF SHARES

REPORT YEAR

PROPERTY CODE

ACCOUNT / REFERENCE NUMBER / CHECK NUMBER

IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL

REPORTED OWNER(S) NAME (exactly as indicated on report)

CLAIMANT(S) NAME

CLAIMANT(S) ADDRESS: STREET ADDRESS

CITY STATE ZIP CODE

DATE PAID TO CLAIMANT OR DATE STOCK REISSUED

AMOUNT NUMBER OF SHARES

Sworn to and subscribed before me this _______ day of _____________________, 20______.

________________________________________

Notary

My commission expires:_____________ ______

PART II CLAIM INFORMATION: (CONTINUED)

PART III HOLDER CERTIFICATION:

I, , a duly authorized

corporate officer of the holder listed above, do hereby certify that the above listed funds or shares, which were listed in the Report

of Abandoned and Unclaimed Property filed by the holder have been paid to the rightful owners or their representatives. The

holder therefore requests reimbursement for such payment.

Signature of Corporate Officer ____________________________________ Date __________________

Name of Representative

PAGE 3 OF 3

TREASURY USE ONLY:

Property ID Number__________________________________

TREASURY USE ONLY:

Property ID Number__________________________________

REPORT YEAR

PROPERTY CODE

ACCOUNT / REFERENCE NUMBER / CHECK NUMBER

IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL

REPORTED OWNER(S) NAME (exactly as indicated on report)

CLAIMANT(S) NAME

CLAIMANT(S) ADDRESS: STREET ADDRESS

CITY STATE ZIP CODE

DATE PAID TO CLAIMANT OR DATE STOCK REISSUED

AMOUNT NUMBER OF SHARES

REPORT YEAR

PROPERTY CODE

ACCOUNT / REFERENCE NUMBER / CHECK NUMBER

IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL

REPORTED OWNER(S) NAME (exactly as indicated on report)

CLAIMANT(S) NAME

CLAIMANT(S) ADDRESS: STREET ADDRESS

CITY STATE ZIP CODE

DATE PAID TO CLAIMANT OR DATE STOCK REISSUED

AMOUNT NUMBER OF SHARES

TOTAL AMOUNT (all pages)

TOTAL NUMBER OF SHARES (all pages)

Title

COMMONWEALTH OF PENNSYLVANIA

TREASURY DEPARTMENT

BUREAU OF UNCLAIMED PROPERTY

PO Box 1837

Harrisburg, PA 17105-1837

$0.00

0.0000

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

INSTRUCTIONS FOR HOLDER REQUEST FOR REIMBURSEMENT

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank INSTRUCTIONS FOR HOLDER REQUEST FOR REIMBURSEMENT Form

Related forms

Fillable INSTRUCTIONS FOR HOLDER REQUEST FOR REIMBURSEMENT

Fill Online, Printable, Fillable, Blank INSTRUCTIONS FOR HOLDER REQUEST FOR REIMBURSEMENT Form

Related forms

First 20 documents completely FREE!