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State of California—Controller’sOffice Report ID# (Remit Report Only)
UNIVERSAL HOLDER FACE SHEET (must be completed and submitted with all reports) Required
UFS-1(Rev. 0 /4 2024)
Upload to the online Holder Reporting Portal with all other required reporting materials.
Notice Report Or Remit Report
Due Before November 1 Due Between June 1 and June 15
Life Insurance Due Before May 1 Life Insurance Due Between December 1 and December 15
Voluntary Compliance Program (See form SCO VCP 02 for due date) Voluntary Compliance Program (See 14F Remit Reminder Letter for due date)
Supplemental Notice Report (For reports with properties that should have been but were not included in the previously submitted Notice Report)
Section A—Holder Information
FEIN Branch Number Report As of Date Check Number / EFT Debit Ref Number (Remit Report Only)
Section B—Holder Contact Information Holder Name
Street Address
P.O. Box Number City State Zip Code Country
Contact Name (For report completion) Title Phone Number Extension
E-mail Address
Section C—Property Owner Contact Information Holder Name
Street Address
P.O. Box Number City State Zip Code Country
Contact Name Title Phone Number Extension
E-mail Address
Section D—Holder Agent Contact (If Applicable) Agent Name
Street Address
P.O. Box Number City State Zip Code Country
Contact Name (For report completion) Title Phone Number Extension
E-mail Address
Section E—Holder CEO/CFO Name Title
Address E-mail Address
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P.O. Box Number City State Zip Code Country
Section F—Holder Report Totals Yes
Total Reported/Remitted Dollars Total Reported/Remitted Shares Includes SafeDepositNoBox
*Any Remittance of $2,000 or more must be paid by Electronic Funds Transfer (EFT), pursuant to Code of Civil Procedures (CCP )Section 1532 .
Section G—Holder Business Information
IncorporationOrganization Type:State: Incorporation Date : / / NAIC SCode:
Charter Federal or State Charter Date: / /
Section H—Demutualization Proceeds This report includes proceeds from the demutualization of an insurance company.
Date of Demutualization CCP Section 1515.5 (a) CCP Section 1515.5 (b) CCP Section 1515.5 (c)
Section I Transfer— Agent (If Applicable) Agent Name
Street Address
P.O. Box Number City State Zip Code Country
Section J—Verification
Section J - Verification If made by an individual, shall be verified by the individual; if made by a partnership, by a partner; if made by an unincorporated association or
private corporation, by an officer; if made by a public corporation, by its chief fiscal officer or other employee authorized by the holder (CCP Section 1530(e)).
The undersigned, declares, under penalty of perjury, that, to the best of (his) (her) knowledge and belief, the following sheets
contain a full, true, and complete report of unclaimed property which is presumed unclaimed under the provisions of Part 3, Title 10, Chapter 7, Code of Civil Procedure,
commencing with Section 1500, and Title 2, California Administrative Code, Sections 1150 et seq. The Undersigned also confirms that all properties not listed on the
Remit Report, which were initially included on the Notice Report, were not remitted due to contact by the apparent owner, or the property being reactivated
or returned to the rightful owner.
Signature Title Date
UFS-1 (Rev 4 4/ 2 )
