PDF document

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ONLINE REPORTING NOW AVAILABLE

HOLDER REPORTING PORTAL LOCATED    AT: 

https://gareporting.unclaimedproperty.com/

IF REPORTING OVER 25 ACCOUNTS, HOLDERS 

ARE REQUIRED TO SUBMIT REPORTS 

THROUGH GEORGIA’S HOLDER REPORTING 

PORTAL.  ALL OTHER HOLDERS ARE 

STRONGLY ENCOURAGED TO DO SO.  

REPORTING THROUGH THE PORTAL 

ELIMINATES THE NEED TO SUBMIT ANY 

FORMS.   ONLINE SUBMISSIONS MUST BE IN 

THE NATIONAL ASSOCIATION OF UNCLAIMED 

PROPERTY ADMINISTRATORS (NAUPA) 

FORMAT. 

FOR MORE INFORMATION EMAIL US AT

UCP.REPORTING@DOR.GA.GOV

        PHONE:  (855 )329-9863

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Securities

Report Forms and Instructions

These forms are intended for reporting any type of securities

and security related cash.

Form UP-1S .................................. Page 27-28

 UP-2S .................................. Page 29-30

 UP-3S .................................. Page 31-32

                                                        (Rev. 0 /5 2022)

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INSTRUCTIONS FOR FORM UP-1S

SECURITIES AND SECURITIES RELATED CASH

• If not reporting online, form UP-1S must accompany all holder reports
• Transfer all securities to Wells Fargo Advisors (see instructions for
UP-3S)

_HOLDER INFORMATION:
This form is to report SECURITIES AND SECURITIES RELATED CASH only. Please type or print your 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.

_REPORT INFORMATION:
IITEM 9A- Enter the total of properties listed on report (each line equals one property).
ITEM 9B- Enter total number of physical securities remitted with this report.
ITEM 9C- Enter total number of DTC stock shares included with this report.
ITEM 9D- Enter total of securities related cash remitted.
ITEM 9E- Enter total number of shares remitted 9B + 9C.
ITEM 10A- Enter total of properties listed on this report (each line equals one property).
ITEM 10B- Enter total number of DTC mutual fund shares included with this report.
ITEM 10C- Enter total number of book shares/DRP shares listed on this report.
ITEM 10D- Enter total securities related cash remitted.
ITEM 10E- Enter total number of mutual funds remitted 10B + 10C.

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

IF FEWER THAN 25 PROPERTIES, YOU MAY CHOOSE TO GO TO OWNER REPORT FORM
(UP-2S) TO PROVIDE A DETAILED LISTING OF THE UNCLAIMED ACCOUNTS REFLECTED IN
ITEM 6E. IF REPORTING 25 PROPERTIES OR MORE, YOU ARE REQUIRED TO SUBMIT
REPORTS AS A NAUPA FILE THROUGH GEORGIA’S HOLDER REPORTING PORTAL.

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UP-1S (Rev. 0 /5 2022)
GEORGIA DEPARTMENT OF REVENUE
UNCLAIMED PROPERTY PROGRAM

2022 HOLDER REPORT SUMMARY

FORM UP-1S

SECURITIES AND SECURITIES RELATED CASH

This form must accompany all holder reports
DID YOU ATTACH A CD? Y [ ] N [ ] ELECTRONIC FILERS: It is not necessary to submit UP-1S if you are reporting online.
Transfer all securities to Wells Fargo Advisors (attach a list of deliveries)
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

REPORT INFORMATION
Delivery and registration of shares remitted (see instructions)
STOCK MUTUAL FUNDS
9A. Total - properties reported _____________________ 10A. Total - properties reported ________________
9B. Total - physical shares _____________________ 10B. Total - DTC shares _____________________
9C. Total - DTC shares ______________________ 10C. Total - book shares/DRP _____________________
9D. Total - securities related - cash remitted _____________________ 10D. Total - securities related - cash remitted _____________________
9E. Total - stock remitted B+C _____________________ 10E. Total - stock remitted B+C _____________________
ENCLOSE CONFIRMATION OF DELIVERY OF SHARES AND MUTUAL FUND STATEMENTS
VERIFICATION STATEMENT
I, ____________________________________, certify that I have caused to be prepared and have examined this report
totaling ____________ shares 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 Date

FOR OFFICE USE ONLY
CD? CHECK NUMBER CHECK DATE CHECK AMOUNT

DATE DEPOSITED BATCH NO. RECEIPT NO. REPORT ID HOLDER NO.

STOCK BATCH ID STOCK RECEIPT ID

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INSTRUCTIONS FOR FORM UP-2S

SECURITIES

The form UP-2S must accompany all holder reports.

Form UP-2S is used to report all securities-related unclaimed property, as well as to report proceeds derived
from the liquidation of such assets. The Unclaimed Property Program uses this information to verify rightful
ownership of persons attempting to claim these accounts.

Specific security delivery instructions for transferring and liquidating securities are found on Page 31. Should
you have any questions, you may contact us by phone (855) 329-9863 or email ucpmail@dor.ga.gov.

Type or print the report.
Enter your business name and federal employer identification number (FEIN) on each page of your
report.
List owners alphabetically by name.

Item 1 - Refer to the Property Codes list on Page 3 and enter the code that best identifies the security
reported.
Item 2 – Enter the identifying account number assigned to the account by your business if applicable.

Item 3 – Enter the owner’s name and compete address as listed on your business records. If the account has
more than one owner, indicate the relationship using the appropriate relationship code from the list on P age 4.

Item 4 – Enter the owner’s social security number (SSN) or tax identification number as shown on your
business records.

Item 5 – Enter owner date of birth.

Item 6 – Enter the date of last transaction or date of last contact with the owner.
Item 7 – Enter the complete name of the stock or fund as shown by the issuing authority.
Item 8 – Enter the stock CUSIP or mutual fund identification number.

Item 9 – Enter the total number of whole shares remitted to include DRP shares. Liquidate all fractional
shares.

Item 10 – Enter cumulative proceeds derived from the liquidation of any fractional shares.
Item 11 – Enter total $ amount of dividends.

Item 12 - Enter total $ amount of columns 10 and 11.
Item 13 – Enter total number of shares per page.
Item 14 – Enter the total $ amount for the page.

Item 15 – If last page, enter the grand total of shares for all pages.

Item 16 – If last page, enter the grand total $ amount for all pages. Make check payable to: Georgia
Department Revenue, Unclaimed Property Program.

Item 17 – Enter total number of properties being reported (this page).
Item 18 – If last page, enter grand total of properties being reported.

Complete a Securities Transfer Memo (UP-3S) for each report submitted.

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UP-2S (Rev. 05/2022)
GEORGIA DEPARTMENT OF                           DETAIL REPORTING FORM UP-2S 
REVENUE UNCLAIMED PROPERTY 
PROGRAM 
                                        SECURITIES AND SECURITIES RELATED CASH 

                           FEDERAL EMPLOYER ID#              BUSINESS NAME 
            2022

                                    When reporting twenty-five (25) properties or more, they must be reported online in NAUPA format. 

STOCK                                                              DATE OF 
PRO-  OWNER                                                  DATE          LAST               CUSIP/                   TOTAL    CASH-IN-LIEU           CASH AMOUNT 
PERTY IDENTIFYING                               OWNER TAX ID OF    TRANS-       NAME OF STOCK FUND                     SHARES   FRACTIONAL   CASH FROM REMITTED AS 
CODE  NUMBER          OWNER'S NAME AND ADDRESS  NUMBER       BIRTH ACTION       ISSUE         NO.                      REMITTED SHARES       DIVIDENDS DUE OWNER 
(1)     (2)                         (3)         (4)          (5)           (6)  (7)           (8)                      (9)      (10)         (11)      (12)

                                                                                (13) TOTAL NUMBER OF SHARES
    (17)  TOTAL PROPERTIES FOR PAGE
                                                                   (14) ENTER TOTAL AMOUNT REMITTED FOR PAGE
      (18) IF LAST PAGE, ENTER GRAND
            TOTAL OF PROPERTIES                     (15) IF LAST PAGE, ENTER GRAND TOTAL OF SHARES FOR ALL PAGES
                                                             (16) IF LAST PAGE, ENTER GRAND TOTAL AMOUNT OF ALL PAGES. 
                                                             MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE
                                                                                UNCLAIMED PROPERTY PROGRAM

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UP-3S(Rev. 0 /5 2022)

INSTRUCTIONS FOR SECURITIES

DTC TRANSFER CONFIRMATION

FORM UP-3S

Please type or print your report.

This report must accompany your “UP-1S – Holder Report Summary Form” and holder report.

ITEM 1 - Enter your HOLDER-ID number as supplied by Georgia Unclaimed Property if known.

ITEM 2 - Enter the date that the report was prepared.

ITEM 3 - Enter the full stock issue name as shown by issuing authority.

ITEM 4 - Enter stock symbol.

ITEM 5 - Enter the CUSIP number for each issue.

ITEM 6 - Enter the total number of shares transferred to Georgia’s Unclaimed Property Custodian – Wells
Fargo Advisors.

ITEM 7 - Enter date that the DTC transfer occurred.

ITEM 8 - Enter grand total of Item 6.

The report must be certified as accurate, as indicated by the signature of an officer of the institution.

Georgia Revenue Commissioner
Tax ID: 58-6002015

Send to:

Georgia Department of Revenue
Unclaimed Property Program
4125 Welcome All Rd Suite 701
Atlanta, GA 30349

REMITTING ABANDONED SECURITIES MUTUAL FUND REGISTRATION

1. Securities must be electronically transferred to Wells Fargo Clearing Services, LLC
Georgia’s custodial account. Use the following FBO State of Georgia
information when making this transfer: Bin #77371939
2801 Market Street
CUSTODIAN - Wells Fargo Advisors St. Louis, Mo. 63103
DTC NUMBER - 0141
GEORGIA’S ACCOUNT NUMBER - 7888-0087 Tax ID: 23-2384840
Branch: 00180
2. Use Form UP-3S to record confirmation of DTC: 0141
securities transfer. REP# 0018007

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UP-3S(Rev. 0 /5 2022)
GEORGIA DEPARTMENT OF REVENUE 
UNCLAIMED PROPERTY PROGRAM

                     2022 SECURITIES DTC TRANSFER CONFIRMATION 

                                                            FORM UP-3S
                              This form must accompany all holder reports.

                                                                                      Page ______ of _______

HOLDER NAME                                                 ADDRESS

DTC #                                                                             FEIN

GA HOLDER ID # (1)                                          HOLDER REPORT DATE (2)

This form is used to notify the Georgia Unclaimed Property Program that all securities reported as unclaimed property have
been transferred to the state’s custodian, Wells Fargo Advisors.  New state reporting requirements mandate the transfer of all
eligible shares using DTC.  Specific instructions for completing this form and transfering the shares can be found in the
accompanying “Instructions for Completion of Form UP-3S.”

                                                                                      TOTAL SHARES DTC TRANSFER
                     STOCK ISSUE NAME                       STOCK SYMBOL CUSIP #      TRANSFERRED  DATE
                          (3)                               (4)          (5)          (6)          (7)

                                      GRAND TOTAL OF SHARES TRANSFERRED  (8)

I, the undersigned, certify that the securities listed above have been successfully transferred via DTC to Wells Fargo Advisors,
custodian for The State of Georgia on the date(s) indicated.

Signed ___________________________________                   Title ________________________________

Date  ______________________

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       Checklist  for Unclaimed Securities

       and Securities Related Cash

Your report should consist of:

   Holder Report Summary Form (UP-1S). (If not reporting electronically)
   Detail Reporting Form (UP-2S) (If not reporting electronically)
    Uploaded NAUPA file at https://gareporting.unclaimedproperty.com/
   Securities DTC Transfer Confirmation (UP-3S). (If not reporting electronically)
    Submitted  electronic  payment  at  https://gareporting.unclaimedproperty.com/  or
    enclosed  a  check  for  the  total  amount  due  payable  to:
    GEORGIA  DEPARTMENT  OF  REVENUE
  All mutual funds, DRP, book entry, etc., statements.  If no statement is included, report    
                                                                                        will be incomplete and not processed.

Send your report package to:

    Georgia Department of Revenue
    Unclaimed Property Program
    4125 Welcome All Rd Suite 701
    Atlanta, GA  30349

Note:  Do not report worthless, non-transferable or restricted
shares.

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ADDITIONAL INSTRUCTIONS AND INFORMATION

REPORT CHECKLIST - Before filing your report, have you?

• Sent owner notification letters to all owners with accounts of $50 or more?

• Signed Form UP-1S statement verification? (If not reporting electronically)

• Submitted payment electronically at https://gareporting.unclaimedproperty.com/ or enclosed a
check for the total amount due payable to GEORGIA DEPARTMENT OF REVENUE

• Included federal tax identification number on all pages of the report?

• Electronic filers: Uploaded NAUPA file at https://gareporting.unclaimedproperty.com/?ctronic
filers: Included ca learly labeled CD and a hard copy of Form UP-1S?

• Securities: Completed DTC Transfer Form UP-3S? (If not reporting electronically)

TO REQUEST AN EXTENSION

• Reports are due by November 1, 2021. Extensions may be granted of up to 90 days.

• Mail or fax a written request to the Unclaimed Property Program at least 30 days prior to the report due
date.

• Provide an estimated filing date and the reason for the extension request.

REMITTING ABANDONED SECURITIES

• Do not report worthless / non-transferable securities / restricted shares.

• Do not report fractional shares. Holders must liquidate fractional shares.

• Securities must be electronically transferred to Georgia’s custodial account. Use the following information
when making this transfer:

CUSTODIAN - Wells Fargo Advisors
DTC NUMBER - 0141
GEORGIA’S ACCOUNT NUMBER - 7888-0087

• All physical certificates must be submitted with the unclaimed property report by November 1. The
certificates must be registered to the GEORGIA REVENUE COMMISSIONER.

NEED MORE HELP?

Georgia’s Unclaimed Property staff will be glad to answer any questions regarding unclaimed property.
Please contact us at:

Georgia Department of Revenue
Unclaimed Property Program
4125 Welcome All Rd Suite 701
Atlanta, GA 30349
Telephone: (855) 329-9863
Fax Line: (404) 724-7013 Email:
ucp.reporting@dor.ga.gov

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