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Rev. 02/2013 |
UP-1 |
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State of Louisiana |
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Department of the Treasury |
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Unclaimed Property Division |
This form may |
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P.O. Box 91010 |
be reproduced |
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Baton Rouge, LA 70821-9010 |
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(225) 219-9400 |
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LOUISIANA REPORT OF UNCLAIMED PROPERTY VERIFICATION |
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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 |
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(If Known) |
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Holder Name: |
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Address 1: |
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Address 2: |
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City, State, Zip: |
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Contact Person: |
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Telephone Number: |
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Fax Number: |
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Email Address: |
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Federal ID Number: |
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State of Incorporation: |
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Date of Incorporation: |
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Primary Business Activity: |
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Did you file a report of |
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Unclaimed Property last year? |
YES |
NO |
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If NO, please explain: |
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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 |
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Total Amount Due From Last Page: |
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$ |
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Interest: |
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$ |
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Penalty: |
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$ |
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Total Remittance: |
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$ |
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Total Number of Shares of Stock: |
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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.
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Signature of Official |
Title |
Date |
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