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