Form Ap1 - Report Of Unclaimed Or Abandoned Property

FORM AP1

STATE OF DELAWARE

Department of Finance

REPORT OF UNCLAIMED

OR ABANDONED PROPERTY

Division of Revenue

P O Box 8931

Verification For Report Year 20_____

Wilmington DE 19899

REPORT INFORMATION

Please Check One

[ ]

Preliminary Report

[ ]

Final Report - Date preliminary report filed ____________________

[ ]

Supplemental report

Date previous report___________________

_________________________________________________________________________

HOLDER INFORMATION

1 -______________________________

Enter Your Federal E.I.#-

___________________________________________________________________________

Company Name:

Address:

___________________________________________________________________________

City:

State:

Zip:

___________________________________________________________________________

State of Incorporation: ___________________ Date of Incorporation: __________________ Primary SIC Code:_________________

Contact Person: ________________________________________________________ Title:__________________________________

Telephone: ________________________________ FAX Number: __________________________________

1. Is the above a successor corporation? Yes___ No___ If you answered yes, please attach a listing of previous corporate names and

date of acquisition.

2. Has the corporation changed names in the past year? Yes___ No___ If yes please enter the following information:

Previous Name

Federal E.I.#

Date of Change

_________________________________________________________________________

REPORT RECAPITULATION

CASH AMOUNT

NUMBER OF SHARES

OWNER & PROPERTY COUNT*

This report:

____________________

_____________________

For final or supplemental reports complete the following:

Preliminary Report:

____________________

_____________________

Additions:

____________________

_____________________

Deletions:

____________________

_____________________

Grand Total:

____________________

_____________________

Advertising Expenses (Bank & Insurance Holders Only): ____________________

REMITTANCE AMOUNT & SHARES:

____________________

_____________________

* Owner count is defined as the aggregate number of property owners; Property count is defined as the total number of individual property items being remitted.

(Ex: Property owned jointly would have two owners, but count as only one piece of property)

_________________________________________________________________________

VERIFICATION

State of_________________________:

County of________________________: ss

________________________________________

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

examined this report as to property presumed abandoned under the Delaware Unclaimed Property Law for the year ending as stated; that I am duly authorized by the holder to execute

this report; and I believe that said report is true, correct and complete as of said date, excepting for such property as has ceased to be abandoned.

__________________________________

________________________________________

Signature

Title

____________

__________,

_________.

Subscribed and sworn to before me this

day of

DOCUMENT NO: 25-06/87/01/05

REVISION DATE: 11/24/08