ONLINE REPORTING NOW AVAILABLE

  HOLDER REPORTING PORTAL LOCATED AT: 

  https://gareporting.unclaimedproperty.com/

  NEGATIVE REPORTING IS REQUIRED.  YOU 

  ARE ENCOURAGE TO SUBMIT YOUR 

NEGATIVE REPORTS ONLINE THROUGH OUR 

  HOLDER REPORTING PORTAL.  NEGATIVE 

REPORTS SUBMITTED THROUGH THE PORTAL 

  DO NOT NEED TO BE IN THE NATIONAL 

  ASSOCIATION OF UNCLAIMED PROPERTY 

  ADMINISTRATORS (NAUPA) FORMAT.

YOU DO NOT NEED TO SUBMIT FORM UP-1N IF 

USING THE HOLDER PORTAL FOR NEGATIVE 

         REPORTING.  

. 

  FOR MORE INFORMATION EMAIL US AT

  UCP.REPORTING@DOR.GA.GOV

         PHONE:  (855 )329-9863

                   INSTRUCTIONS FOR FORM UP-1N

                     NEGATIVE REPORTS ARE REQUIRED!

               It is not necessary to submit this form if you are reporting online.

HOLDER INFORMATION:

This form is for holders with no unclaimed property to report.

ITEM 1-  Enter your federal employer identification number.

ITEM 2-  Enter your business name and mailing address.

ITEM 3-  If this report is being prepared by an agent on behalf of the business, enter the agent’s name and 
address.

ITEM 4-  Enter the name of the person completing the form.

ITEM 5-  Enter the telephone number for the person completing the form.

ITEM 6-  Enter the e-mail address for the person completing the form.

ITEM 7-  Enter the date your business was incorporated or registered.

ITEM 8-  Enter the state where your business is registered or incorporated.

ITEM 9-   Enter primary business activity.

ITEM 10-  Enter number of employees.

ITEM 11-   Enter annual sales.

ITEM 12-   Enter annual sales in Georgia.

ITEM 13-   Enter total assets.

VERIFICATION:
The report must be certified by a CFO, partner or company officer.

                                                 35

UP-1N (Rev. 0 /5 2022) 

                                                          ZERO /         NEGATIVE

                                   HOLDER REPORT FORM

                                                           2022

                                         Negative reports are required!

                                            ARE YOU A 1ST TIME FILER?   Y [    ]    N [    ]

HOLDER INFORMATION
1.  FEDERAL EMPLOYER ID#                       2.  HOLDER (Business Name)

ADDRESS

CITY, STATE, ZIP CODE

3.  IS THIS REPORT BEING PREPARED BY AN AGENT ON BEHALF OF THE HOLDER?    Y  [    ]    N  [    ]            IF YES, FURNISH AGENT NAME
AND ADDRESS:

4.  NAME OF CONTACT PERSON                                 5.  TELEPHONE                       6.  E-MAIL ADDRESS
                                                           (          )

7.  DATE OF INCORPORATION   8.  STATE OF INCORPORATION                 9.  PRIMARY BUSINESS ACTIVITY

10.  NO. OF EMPLOYESS    11.  ANNUAL SALES                             12.  ANNUAL SALES IN GA 13.  TOTAL ASSETS

REPORT INFORMATION
INTANGIBLE PROPERTY - (Outstanding Checks) 
14a.  Total accounts $50 or more             0              14b.  Dollar Value $                0
14c.  Total accounts less than $50           0              14d.  Dollar Value $                0
                                                             14e.  Report Total $                         0
OTHER PROPERTY (Safe deposit boxes, stocks, mutual funds)
14f.  Number of shares of stock or mutual fund shares       0
14g.  Number of safe deposit boxes/safekeeping items         0
VERIFICATION  STATEMENT
I, _______________________________, certify that I have caused to be prepared and have examined this 
report totaling $ _____________ 0       and as to property presumed abandoned under the Disposition of Unclaimed Property 
Act for the year ended as stated, that I am duly authorized to execute this verification by the holder and that I believe said 
report to be true, correct and complete as of said date to the best of my knowledge.

                       Signature of Responsible Officer                           Printed or Typed Name    of    Responsible Officer

                       Title of Responsible Officer/Agent                                                  Date