AP- 1        REPORT OF ABANDONED AND UNCLAIMED PROPERTY VERIFICATION AND CHECKLIST

HOLDER INFORMATION:
Holder’s Name  ______________________________________________________________________________ 
Federal EIN Number  __________________________________________________________________________ 
Contact Name  ___________________________ Phone  _____________  Email  ________________________                            
Address 1  __________________________________________________________________________________ 
City  ____________________________________________ State   _______ Zip Code  _____________________                         
County  ___________________________           State of Incorporation _________________          Report Year __________

Industry Type: (check box)        __ Other Services (Except Public)    __ County                     __ Transportation
__ Agriculture, Forestry, Fishing __ Professional & Scientific        __ School District             __ Police Departments
__ Mining & Oil/Gas               __ Management of Companies          __ Manufacturing               __ Correctional Institutions
__ Utilities                      __ Administrative & Support         __ Retail                      __ Other State Government Agencies 
__ Construction                   __ Educational Services             __ Information Technology      __ Finance
__ Wholesale Trade                __ Health Care & Social Assistance  __ Municipal Authorities       __ Insurance
__ Newspapers & TV Broadcasting   __ Arts, Entertainment & Recreation __ Consulting                  __ General
__ Finance & Insurance            __ Accommodation & Food Service     __ Trucking

Is this the first time your organization has filed 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).

                                  Signature                                                     Date

                                  Print Name                                                    Title
Report for Period Ended December 31, 
Mail to: Post Office – standard first class and certified mail         Overnight (UPS, FedEx, Post Office) and all other Courier deliveries 
        COMMONWEALTH OF PENN                                           LOCKBOX SERVICES (783473)
        UNCLAIMED PROPERTY                                             COMMONWEALTH OF PENN UNCLAIMED PROPERTY
        P O BOX 783473                                                 MAC Y1372-045
        PHILADELPHIA, PA 19178- 3473                                   401 MARKET STREET
                                                                       PHILADELPHIA, PA 19106