Form Up-1 - Louisiana Report Of Unclaimed Property Verification And Checklist - 2000
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1
2R-3001-L (8/00)
UP-1
State of Louisiana
Department of the Treasury
This form may
Unclaimed Property Division
be reproduced.
P.O. Box 91010
Baton Rouge, LA 70821-9010
(225) 219-9400
Louisiana Report of Unclaimed Property Verification and Checklist
Holder account number
Page
of
Report year
Period covered
to
File on or 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 name ______________________________________________________________________
Holder address 1 ____________________________________________________________________
Holder address 2 ____________________________________________________________________
Holder city, state, zip __________________________________________________________________
Contact person ______________________________________________________________________
Telephone number _______________________________ Fax number _________________________
Email address _______________________________________________________________________
Federal ID number ___________________________ _ _________ ________________________________
State of incorporation _____________________________ Date of incorporation ___________________
Standard Industrial Classification Code (SIC) _ _______________________________________________
Primary business activity _______________________________________________________________
Did you file a report of unclaimed property last year? ________________________________________
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.
Name ______________________________________________________________________________
Address ____________________________________________________________________________
City, state, ZIP _______________________________________________________________________
Every person, corporation, or other business association, banking or financial organization, life insurance
corporation, utility, court, or public authority required to file a report of unclaimed property under the
provisions of Louisiana Revised Statutes 9:151–181 must complete the checklist on the back of this form.
Your remittance must accompany this report.
Please mark one.
Total amount due from last page _______________________________
Annual report
Interest _______________________________
(due November 1)
Amended report
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 sheets contain a full, true, and complete
report consisting of __________ page(s) totaling $ _______________ as to property presumed
abandoned under the provisions of La. R.S. 9:151-181 as of __________________ , ________ .
6933
__________________________
_______________________________
__________
Signature of official
Title
Date
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