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State of California—Controller’sOffice                                                                                                                                                                                                                                                                                                                   Report ID#  (Remit Report Only) 
UNIVERSAL HOLDER FACE SHEET                                                                                                                                                                                                                                         (must be completed and attached with all reports)                                           Required 
UFS-1(Rev. 01/15) 
Mail to: Office of State Controller Malia M. Cohen,                                                                                                                                                                                                                 Unclaimed Property Division, P.O. Box 942850, Sacramento, CA 94250 
Notice Report                                                                                                                                                                                                                                                           Or                        Remit Report 
Due Before November 1 or                                                                                                                                                                                                                                                                       Due Between June 1 and June 15 or 
Life Insurance Due Before May 1                                                                                                                                                                                                                                                                   Life Insurance Due Between December 1 and December 15 
Supplemental Notice Report                                                 Notice Report cannotnot (Properties included the on                               Report andRemit be listed the on                     aon must be reported Supplemental Report)Notice 
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 
P.O. Box Number                                                                                                                                                                              City                                                                                      State                           Zip Code                           Country 

Section F—Holder Report Totals                                                                                                                                                                                                                                                                                                                                       Yes
                                                                                                                                                                                                                                                                    Total Reported/Remitted Dollars          Total Reported/Remitted Shares                  Includes SafeDepositNoBox  

*Any Remittance of $20,000 or       more must be paid by Electronic Funds Transfer (EFT), pursuant to                                                                                                                                                                                                                         Code of Civil Procedures (CCP )Section 1532.
Section GHolder Business Information
Organization Type:                                                                                                                                                                                                                                                                                        NAISC Code: 
Incorporation State:                 Incorporation Date :                                                                                                                                                                                                                 /    /                          Charter             Federal       or    State     Charter Date:    /  / 

Section HDemutualization 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 JVerification
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 due to contact by the apparent owner, or the property being reactivated or returned to the 
rightful owner.  
Signature                                                                                                                                                                                                                                                                                                 Title                                                  Date 

UFS-1 (Rev12 22    / ) 



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                 Universal Holder Face Sheet Instructions 

The Universal Holder Face Sheet (UFS-1) form must be completed and submitted with all 
reports.  

Notice Report: Check this box when submitting a Holder Notice Report. This report is due 
annually prior to November 1 or prior to May 1 for life insurance companies. If the holder 
identifies accounts that were not included on the original Holder Notice Report, they must be 
reported on a separate Supplemental Notice Report and cannot be included on the Holder 
Remit Report.  

Remit Report: Check this box when submitting a Holder Remit Report. This report is due 
between June 1-15 or between December 1-15 for life insurance companies.  

Report ID# (Remit Report Only): Please list the Holder Remit Report ID number located on 
the upper right-hand corner of the Holder Remit Reminder Letter (14F). If you did not receive a 
14F letter, please contact the Reporting Unit at 916-464-6284 for assistance.  

Section A - Holder Information: Please provide the Federal Employer Identification Number 
(FEIN), branch number (if applicable), report “As of” date, and check number/EFT debit 
reference number (Holder Remit Report only). The FEIN and report “As of” date are 
required.Failure to provide this information will result in the report being rejected.     

FEIN: Enter the FEIN number.  
Branch Number: Enter the branch number, if applicable.
Report “As of” date: The “As of” date is the cut-off date of your reporting cycle (either 
        June 30th or the holder’s fiscal year end). If the fiscal year-end date falls between 
        January 1 and June 30, the report is due before November 1 of the same year. If the 
        fiscal year end date falls between July 1 and December 31, the report is due before 
        November 1 of the following year. This date is not the signature date or report due 
        date. The report “As of” date for life insurance companies and insurance corporation 
        demutualization or reorganization proceeds is December 31 [CCP section 1530 (d)]. 
Check Number/EFT Debit Ref Number: Applies to Holder Remit Report only.

Section B – Holder Contact Information: The holder name is required. The holder is the 
company reporting the property. Please provide complete contact information for the person 
in the company responsible for completing the report. This contact information will be used 
by the State Controller's Office to contact the holder with questions regarding the report. 
Failure to provide this information will result in the report being rejected.  

Section C – Property Owner Contact Information: Please provide complete contact 
information for the person responsible for handling inquiries from owners attempting to claim 
their property. If you are submitting a disk, the contact information on the UFS-1 should 
match the contact information on the disk. The contact information on the UFS-1 (paper 
reports) or the disk (electronic reports) will be printed on notices to property owners. If this 
section is left blank, the contact information provided in Section B will be printed on notices 
to property owners. During the notice period, the contact person listed in Section C should 
expect phone calls from owners claiming their property.  

Section D – Holder Agent Contact (If Applicable): If the report is completed by a reporting 
agent (third-party vendor), enter the agent’s name and contact information. If filing 
electronically, please ensure the contact information is correct on the disk. 



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Section E – Holder CEO/CFO: Please provide complete contact information for the 
company’s Chief Financial Officer (CFO) or Chief Executive Officer (CEO), including a valid 
mailing address.  

Section F – Holder Report Totals: The total dollar amount (or share amount) is required. 
Please fill in the total dollar amount reported (Notice cycle) or remitted (Remit cycle). Fill in the 
total shares reported for each cycle. Fill in zero (0) if no shares are remitted. Shares refer only 
to securities such as stock and mutual funds. Check yes or no to indicate whether or not the 
report includes safe deposit box contents or safe keeping items (property types SD01, SD02, 
SD03). Do not enclose safe deposit properties when reporting (Notice or Remit).  

Section G – Holder Business Information: Enter the holder’s type of organization, state and 
date of incorporation, four digit North American Industry Classification System (NAICS) code, 
and charter type and date. 

Section H – Demutualization Proceeds: Applies only if the report contains unclaimed 
proceeds from the demutualization of an insurance company. More information can be found 
in the Important Considerations section of the Unclaimed Property Holder Handbook, 
available on the website at www.sco.ca.gov/Files-UPD/guide_rptg_holderhandbook.pdf.

Section I – Transfer Agent (If Applicable): If a holder is using a transfer agent for     
security-related properties, please list the name and the address of the transfer agent. 

Section J – Verification: The signature of an authorized person is required. For reports to 
be properly verified, the California State Controller’s Office requires a signature on all UFS-1 
forms. Reports with UFS-1 forms that do not contain a signature may be subject to interest at 
a rate of 12% per annum from the date the property should have been reported or remitted as 
prescribed by CCP section 1577. The UFS-1 form includes an affirmation stating that all 
accounts not included on the Holder Remit Report, which were included on the Holder Notice 
Report, are absent only due to reactivation or reunification of property with the owner.  

Reporting agents submitting multiple reports at one time will be allowed to submit a transmittal 
letter with a signature that lists all reports being submitted. The transmittal letter must contain 
the signature of  aperson who meets the criteria under CCP section 1530(e) and the UFS-1 
verification language specified in the General Reporting Instructions section of the Unclaimed 
Property Holder Handbook. Multiple reports submitted by reporting agents that do not meet 
this criterion may be subject to interest at a rate of 12% per year from the date the property 
should have been reported or remitted as prescribed by CCP section 1577. 






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