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Form Name	Form Ap 1 Ins
Form Length	2 pages
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Fillable fields	0
Avg. time to fill out	30 sec
Other names	ma 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-

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*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

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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

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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

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_____	_____	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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