AP- 1 NEG                 NEGATIVE REPORTING FORM FOR ABANDONED AND UNCLAIMED PROPERTY

Company Information:
Company Name _____________________________________________________________________________________
Federal ID Number (FEIN) _____________________________________________________________________________
Contact Name _____________________________________ Phone _________________ Email _____________________
Address 1 __________________________________________________________________________________________
City ________________________________________________________ State ___________ Zip Code _______________
County ________________________________________________ State of Incorporation _________________________
Assets $ __________________________________  Annual Sales $ ___________________
Number of Employees __________________  Report Year __________________________

Industry Type: (check box)             _ County Controller                 _ Insurance                         _ Public Administration
  _ Accommodation & Food Service       _ County Sheriff                    _ Management of Companies           _ Real Estate Rental & Lease
  _ Administrative & Support           _ County/State Nursing Homes        _ Manufacturing                     _ Retail
  _ Agriculture, Forestry, Fishing     _ County/State Treasurer            _ Mining & Oil/Gas                  _ School District
  _ Arts, Entertainment & Recreation   _ Educational Services              _ Municipal Authorities             _ Transportation
  _ Construction                       _ Finance                           _ Newspapers & TV Broadcasting      _ Trucking
  _ Consulting                         _ Finance & Insurance               _ Other Services (Except Public)    _ Utilities
  _ Correctional Institutions          _ General                           _ Other State Government Agencies   _ Wholesale Trade
  _ County                             _ Health Care & Social Assistance   _ Police Departments
  _ County Clerks of Court & Proth     _ Information Technology            _ Professional & Scientific

HOLDER VERIFICATION:
The Pennsylvania Treasury, Bureau of Unclaimed Property requires the signature of the Chief Financial Officer or other 
corporate officer responsible for the financial operations of the company.
The undersigned hereby verifies that an annual review of the books and records of
________________________________________________________________________ has been performed.
                                                              (name of company)
As a result of this review, we can definitively state that this company is not in possession of any unclaimed property that 
is due and reportable to the Commonwealth of Pennsylvania.
Mail to: Bureau of Unclaimed Property, P.O. Box 1837, Harrisburg, PA 17105
____________________________________________________________________________ has policies and
                                                              (name of company)
procedures in place to account for dormant property and eventually report unclaimed property to the Commonwealth of
Pennsylvania in accordance with 72 P.S. § 1301 et.seq.
____________________________________________________________________________ understands that
                                                              (name of company)
unreported and/or undelivered property is subject to 12% interest in accordance with 72 P.S. §§ 1301.24, and other 
penalties as provided for in statute, including but not limited to 72 P.S. § 1301.25 (relating to penalties). The undersigned 
herby verifies that the statements set forth in this holder report are true, and acknowledges that any false statements 
contained therein are subject to the penalties of 18 Pa. C.S.A § 4904 (relating to unsworn falsification to authorities)
____________________________________________                ___________________________________________
                              Signature                                                               Date
____________________________________________                              ___________________________________________
                              Print Name                                                              Title