Louisiana Up 1 Form – Fill Out and Use This PDF

	Rev. 02/2013	UP-1
	State of Louisiana
	Department of the Treasury
	Unclaimed Property Division	This form may
	P.O. Box 91010	be reproduced
	Baton Rouge, LA 70821-9010
	(225) 219-9400
	LOUISIANA REPORT OF UNCLAIMED PROPERTY VERIFICATION

Report Year: __________________________________ Period Covered: _________________ to ________________

FILE BEFORE NOVEMBER 1.

If the due date falls on a weekend or holiday, the report is due on the next business day and becomes delinquent on the first day thereafter.

Holder Account Number
(If Known)
Holder Name:
Address 1:
Address 2:
City, State, Zip:
Contact Person:
Telephone Number:		Fax Number:
Email Address:
Federal ID Number:
State of Incorporation:		Date of Incorporation:
Primary Business Activity:
Did you file a report of
Unclaimed Property last year?	YES	NO
If NO, please explain:

If you are the successor to a previous holder of the property, or if you have changed your name or address, please make corrections and list your previous name below:

Previous Name:

Previous Address:

Previous City, State, Zip:

YOUR REMITTANCE MUST ACCOMPANY THIS REPORT

PLEASE MARK ONE:	Annual Report (DUE NOVEMBER 1)		Supplemental/Additional Report
	Total Amount Due From Last Page:		$
	Interest:		$
	Penalty:		$
	Total Remittance:		$
	Total Number of Shares of Stock:

OFFICIAL VERIFICATION OF REPORT

I, __________________________________, hereby declare, under penalty of perjury, that to the best of my knowledge

and belief, the following documentation contain a full, true, and complete report consisting of ____ page(s) totaling

$____________ regarding to the property presumed abandoned, remitted with this documentation, under the

provisions of La. R.S. 9:151-181 as of __________________, _____.

I further declare that this documentation contains complete and accurate information pertaining to the interest-bearing nature of all properties, remitted with this documentation contained therein. Specifically, I acknowledge and declare that this report accurately reflects whether each unit of remitted property, listed in the attached documentation, bears interest or is not interest bearing. I understand and acknowledge that failure to designate a remitted unit of property as bearing interest is equivalent to an express statement that such property is not interest bearing.

_____________________________________	______________________________	__________________________
Signature of Official	Title	Date