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 SafeDepositNoBox
*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 G—Holder Business Information
Organization Type: NAISC Code:
Incorporation State: Incorporation Date : / / 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 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 / )