Mass Unclaimed Property Form Details

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QuestionAnswer
Form NameForm Ap 1 Ins
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesma report unclaimed, ma form ap 1, ma form unclaimed, mass unclaimed property form

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OUT 2014 AP-1 REPORT FORMS

FORM AP-1 INS

REV 8/2014

COMMONWEALTH OF MASSACHUSETTS

DEPARTMENT OF THE STATE TREASURER

UNCLAIMED PROPERTY DIVISION

One Ashburton Place, 12th Floor

Boston, Massachusetts 02108-1608

(617)367-3900

http://www.findmassmoney.com

Deborah B. Goldberg

TREASURER AND RECEIVER GENERAL

REPORT OF UNCLAIMED PROPERTY AP-1

In accordance with M.G.L. c. 200A, every person, corporation, or other business association, banking or financial organization, life insurance corporation, utility, court or public authority is required to complete this form and submit it together with their unclaimed property to the State Treasury, Unclaimed Property Division, by November 1 of each year (May 1 for Life Insurance companies). All reports must be filed electronically. A preformatted diskette package is available upon request at no charge to the holder by contacting the Unclaimed Property Division at the address and telephone number listed above. Reports not conforming to the prescribed reporting requirements will be returned to the holder and may be subject to fines and penalties (M.G.L. c 200A s 12). Please refer to the enclosed instructions.

PULL-

HO

*Unclaimed Property Holder number _______________________

Holder Name ___________________________________________

Contact Person _________________________________________

Address _______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

Did you file a report of unclaimed property last year? __________

Federal Employer Tax I.D.# ____________________

Telephone # ____________________________________

List on a separate sheet the name and address of all previous holders of the property, if you are a successor or if your company name has changed during the time period in which you have held the property.

*UNCLAIMED PROPERTY HOLDER NUMBER is the number assigned to you by the Unclaimed Property Division.

PULL-OUT 2014 AP-1 REPORT FORMS

Primary business activity of your company ____________________________________________________________________

Parent Company ___________________ State of Incorporation _________________ Date of Incorporation ______________

Verification for period ended _____________________

Check box if filing a Negative Report ($0.00)

Type of Report included (check one): CD _____________ Diskette ____ FTP ________

Name of Service Bureau __________________________ Telephone # ___________________________

REPORT TOTALS

(a) AGGREGATE TOTAL

$ _________________________________

(b) OWNER TOTAL

$ _________________________________

TOTAL OF CASH AMOUNT REPORTED

$ _________________________________

TOTAL NUMBER OF SHARES REPORTED

no. _______________________________

(If you are reporting more than one issue list each and the totals on a separate sheet.)

Number Of Owners Reported

no. _______________________________

Check box if remittance is sent by Electronic Funds Transfer (EFT)

VERIFICATION

I,______________________________________, being duly sworn, on oath depose and state that I have caused to be

prepared and have examined this report of property presumed abandoned under the Massachusetts Unclaimed Property Law Chapter 200A, and that I am duly authorized to execute this verification and believe said report is true, correct and complete as of said date.

On this ____ day of ____________, 20___, before me, the undersigned notary

public, personally appeared________________________(name of document

signer), proved to me through satisfactory evidence of identification, which were

________________________, to be the person who signed the preceeding or

attached document in my presence, and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of (his)(her) knowledge and belief.

____________________________(official signature and seal of notary)

(OVER)

FORM AP-1 INS

REV 8/2014

CHECKLIST OF PROPERTY REPORTED

YES

NO

ACCOUNT BALANCES (3 years inactive)

YES

NO

TRUST, EQUITY AND

 

 

 

 

 

DEBT ACCOUNTS (3 years inactive)

_____

_____ A. Checking accounts

_____

_____

A. Paying agent accounts

_____

_____

B. Savings accounts

_____

_____

B. Unclaimed dividends (portfolio)

_____

_____

C. Matured certificates of deposit

_____

_____

C. Funds held in a fiduciary capacity

 

 

or savings certificates

 

 

 

 

_____

_____

D. Christmas Club accounts

_____

_____

D. Funds paid toward the purchase of

 

 

 

 

 

 

shares, or interest in a financial or

 

 

 

 

 

 

business organization

_____

_____

E. Money on deposit to secure funds

_____

_____

E. Funds received for redemption of

 

 

 

 

 

 

stocks and bonds

_____ _____ F. Security deposits

_____

_____

F. Stocks (underlying and undeliverable)

_____

_____

G. Unidentified deposits

_____

_____

G. Bonds (matured bond principal)

_____

_____

H. Suspense accounts

_____

_____

H. Any other certificates of ownership

_____

_____

I. Any sum owing to a shareholder,

_____

_____

I.

Suspense liabilities

 

 

certificate holder, member, bond

 

 

 

 

 

 

holder or other security holder, or

 

 

 

 

 

 

participating member of a cooperative,

YES

NO

OFFICIAL CHECKS (3 years inactive)

 

 

such as:

 

 

 

 

_____

_____

1. dividends (underlying and undeliverable)

_____

_____

A. Certified checks

_____

_____

2. interest

_____

_____

B. Cashier’s checks

_____

_____

3. principal payments

_____

_____

C. Registered checks

_____

_____

4. equity payments

_____

_____

D. Treasurer’s checks

_____

_____

5. profits

_____

_____

E. Drafts

_____

_____

6. other distributions

_____

_____

F. Warrants

_____

_____

J. Escrow Funds

_____

_____

G. Money orders

 

 

 

_____

_____

H. Travelers checks (15 years inactive)

 

 

 

_____

_____

I.

Foreign exchange

 

 

 

_____

_____

J.

Other official checks or exchange items

PULL-OUT 2014 AP-1 REPORT FORMS

MISCELLANEOUS CHECKS AND

INTANGIBLE PERSONAL PROPERTY

HELD IN THE ORDINARY COURSE

OF BUSINESS (3 years inactive)

YES

NO

 

YES

NO

INSURANCE (3 years inactive)

_____

_____ A. Wages, payroll or salary

_____

_____

A. Amounts due and payable under

 

 

 

 

 

terms of insurance policies

_____

_____

B. Commissions

_____

_____

B. Claim payments

_____

_____

C. Expense checks

_____

_____

C. Drafts not presented for payment

_____

_____

D. Workman’s Compensation benefits

_____

_____

D. Matured whole life, term endowment

_____

_____

E. Pension checks

_____

_____

E. Other amounts due under insurance

 

 

 

 

 

policies or annuities, policy terms or

_____

_____

F. Credit checks or memos

 

 

supplementary contracts

_____

_____

G. Payments for goods and services

_____

_____

F. Premium Refunds

_____

_____

H. Customer overpayment

YES

NO

UTILITIES (3 years inactive)

_____

_____

I. Unidentified remittances

 

 

 

_____

_____

J. Non-refunded overcharges

_____

_____

A. Utility deposits

_____

_____

K. Accounts payable

_____

_____

B. Membership fees

_____

_____

L. Credit balances-accounts receivables

_____

_____

C. Refunds or rebates

_____

_____

M Discounts due

 

 

 

_____

_____

N. Refunds or rebates

 

 

 

_____

_____

O. Vendor checks

YES

NO

DISSOLUTIONS/LIQUIDATIONS (1 year)

_____

_____

P. Mineral proceeds

 

 

 

_____

_____

Q. Royalties

_____

_____

All property distributable in the course

_____

_____

R. Any other miscellaneous

 

 

of voluntary or involuntary dissolution or

 

 

outstanding checks

 

 

liquidation which is unclaimed within

_____

_____

S. Any checks that have been written off to income

 

one year after the date for final distri-

_____

_____

T. Any other miscellaneous intangible

 

 

bution is presumed abandoned.

 

 

personal property

 

 

 

YES

NO

COURT DEPOSITS (3 years inactive)

YES

NO

TANGIBLE PROPERTY (7 years inactive)

_____ _____

A. Escrow funds

_____ _____

A. Contents of safe deposit boxes

_____ _____

B. Condemnation awards

_____ _____

B. Contents of any other safekeeping

_____ _____

C. Missing heirs funds

_____ _____

depository

_____ _____

D. Suspense accounts

_____ _____

C. Other tangible property

_____ _____

E. Any other type of deposit made with

 

 

 

 

 

a court or public authority

 

 

 

PULL-OUT 2014 AP-1 REPORT FORMS

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