INSTRUCTIONS FOR HOLDER REQUEST FOR REIMBURSEMENT
PURPOSE: A holder of abandoned and unclaimed property must complete this form to seek
reimbursement from the Treasury Department for funds or shares which were paid by the
holder to the Treasury Department and for which the righul owner (or his representave)
has submied a claim to the holder for the monies or shares.
INSTRUCTIONS:
1) Complete the form as outlined below.
2) If claim is greater than $10,000, provide signature idencaon in the form of a drivers
license or signed work idencaon card or badge.
3) Provide proof of payment. No reimbursement will be honored without proof of
payment in the form of a legible, readable copy of the cancelled check or reissued stock
cercate, or documentaon that the customers account has in fact been reacvated,
including the date of said reacvaon.
COMPLETION OF FORM: All informaon must be accurate and complete. As long as the report year is listed on each
line, mulple owners may be listed on one AP-5 form. An original form must be submied;
no photocopies will be accepted.
Part I. Holder Informaon: Company Name, address to send reimbursement check,
telephone number and EIN (Employer Idencaon Number) of the holder.
Part II. Claim Informaon: Enter all data necessary to idenfy property for which the holder is
seeking reimbursement. The idencaon data entered on this form must be idencal
to the informaon included on the Report of Abandoned and Unclaimed Property
(AP-2) submied to the Treasury Department. The basic informaon data includes:
1) Report Year.
2) Property Code - the two digit code for the property claimed as dened on the
Summary Sheet of Reported Items (AP-3) or Property Codes (AP-3A).
3) Account/Reference/Check/Number - the idencaon number for the property
which was entered in Column 1 of the AP-2.
4) If the property was reported in the aggregate, specify the aggregate total.
5) Owner(s) Name and Address - the full name(s) and address(es) of the owner(s)
as shown on the AP-2. If “unknown” at me of report, provide name and
current address on form.
6) Claimant(s) Name and Address - the full name(s) and address(es) of the
person(s) who led the claim if dierent than the owner.
7) Date Paid to Claimant or Date Stock Reissued - the date the claim was paid to
the owner (or his representave) or when the account was reacvated by the
holder, or when the stock cercate was reissued.
8) Amount - the dollar amount or number of shares originally transmied by the
holder to the Treasury Department.
9) Total Amount (all pages); Total Number of Shares (all pages) - the amount/number
of shares expected to be reimbursed to the holder by the Treasury Department.
Part III. Holder Cercaon: This notarized statement must be completed before Treasury
will process the request for reimbursement and make payment. Proof that the
claimant was paid and entled to the property must be submied with each and
every holder request for reimbursement. Signature must be of a corporate ocer.
INTEREST: The Treasury Department shall pay interest at the prevailing rate for overpayments pursuant
to secon 806.1 of the Fiscal Code. 72 P.S. Secon 1301.14.
AP-5 INSTRUCTIONS
EIN NUMBER
NAME OF HOLDER
STREET ADDRESS
CITY STATE ZIP CODE
CONTACT PERSON TELEPHONE EXT
HOLDER REQUEST FOR REIMBURSEMENT For funds paid to the Department
PAGE 1 OF 3
PART I HOLDER INFORMATION: (see instructions for claim completion)
PART II CLAIM INFORMATION:
(Please print or type)
TREASURY USE ONLY:
Property ID Number__________________________________
TREASURY USE ONLY:
Property ID Number__________________________________
REPORT YEAR
PROPERTY CODE
ACCOUNT / REFERENCE NUMBER / CHECK NUMBER
IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL
REPORTED OWNER(S) NAME (exactly as indicated on report)
CLAIMANT(S) NAME
CLAIMANT(S) ADDRESS: STREET ADDRESS
CITY STATE ZIP CODE
DATE PAID TO CLAIMANT OR DATE STOCK REISSUED
AMOUNT NUMBER OF SHARES
REPORT YEAR
PROPERTY CODE
ACCOUNT / REFERENCE NUMBER / CHECK NUMBER
IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL
REPORTED OWNER(S) NAME (exactly as indicated on report)
CLAIMANT(S) NAME
CLAIMANT(S) ADDRESS: STREET ADDRESS
CITY STATE ZIP CODE
DATE PAID TO CLAIMANT OR DATE STOCK REISSUED
AMOUNT NUMBER OF SHARES
Claim Number ________________________
Date Received ________________________
Holder EIN ____________________________
Prepared By ___________________________
TREASURY USE ONLY:
(2-10)
AP- 5
PART II CLAIM INFORMATION: (CONTINUED)
PAGE 2 OF 3
TREASURY USE ONLY:
Property ID Number__________________________________
TREASURY USE ONLY:
Property ID Number__________________________________
TREASURY USE ONLY:
Property ID Number__________________________________
REPORT YEAR
PROPERTY CODE
ACCOUNT / REFERENCE NUMBER / CHECK NUMBER
IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL
REPORTED OWNER(S) NAME (exactly as indicated on report)
CLAIMANT(S) NAME
CLAIMANT(S) ADDRESS: STREET ADDRESS
CITY STATE ZIP CODE
DATE PAID TO CLAIMANT OR DATE STOCK REISSUED
AMOUNT NUMBER OF SHARES
REPORT YEAR
PROPERTY CODE
ACCOUNT / REFERENCE NUMBER / CHECK NUMBER
IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL
REPORTED OWNER(S) NAME (exactly as indicated on report)
CLAIMANT(S) NAME
CLAIMANT(S) ADDRESS: STREET ADDRESS
CITY STATE ZIP CODE
DATE PAID TO CLAIMANT OR DATE STOCK REISSUED
AMOUNT NUMBER OF SHARES
REPORT YEAR
PROPERTY CODE
ACCOUNT / REFERENCE NUMBER / CHECK NUMBER
IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL
REPORTED OWNER(S) NAME (exactly as indicated on report)
CLAIMANT(S) NAME
CLAIMANT(S) ADDRESS: STREET ADDRESS
CITY STATE ZIP CODE
DATE PAID TO CLAIMANT OR DATE STOCK REISSUED
AMOUNT NUMBER OF SHARES
Sworn to and subscribed before me this _______ day of _____________________, 20______.
________________________________________
Notary
My commission expires:_____________ ______
PART II CLAIM INFORMATION: (CONTINUED)
PART III HOLDER CERTIFICATION:
I, , a duly authorized
corporate officer of the holder listed above, do hereby certify that the above listed funds or shares, which were listed in the Report
of Abandoned and Unclaimed Property filed by the holder have been paid to the rightful owners or their representatives. The
holder therefore requests reimbursement for such payment.
Signature of Corporate Officer ____________________________________ Date __________________
Name of Representative
PAGE 3 OF 3
TREASURY USE ONLY:
Property ID Number__________________________________
TREASURY USE ONLY:
Property ID Number__________________________________
REPORT YEAR
PROPERTY CODE
ACCOUNT / REFERENCE NUMBER / CHECK NUMBER
IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL
REPORTED OWNER(S) NAME (exactly as indicated on report)
CLAIMANT(S) NAME
CLAIMANT(S) ADDRESS: STREET ADDRESS
CITY STATE ZIP CODE
DATE PAID TO CLAIMANT OR DATE STOCK REISSUED
AMOUNT NUMBER OF SHARES
REPORT YEAR
PROPERTY CODE
ACCOUNT / REFERENCE NUMBER / CHECK NUMBER
IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL
REPORTED OWNER(S) NAME (exactly as indicated on report)
CLAIMANT(S) NAME
CLAIMANT(S) ADDRESS: STREET ADDRESS
CITY STATE ZIP CODE
DATE PAID TO CLAIMANT OR DATE STOCK REISSUED
AMOUNT NUMBER OF SHARES
TOTAL AMOUNT (all pages)
TOTAL NUMBER OF SHARES (all pages)
Title
COMMONWEALTH OF PENNSYLVANIA
TREASURY DEPARTMENT
BUREAU OF UNCLAIMED PROPERTY
PO Box 1837
Harrisburg, PA 17105-1837
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