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 righul owner (or his representave)
has submied 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 idencaon in the form of a drivers
license or signed work idencaon 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
cercate, or documentaon that the customer’s account has in fact been reacvated,
including the date of said reacvaon.
COMPLETION OF FORM: All informaon must be accurate and complete. As long as the report year is listed on each
line, mulple owners may be listed on one AP-5 form. An original form must be submied;
no photocopies will be accepted.
Part I. Holder Informaon: Company Name, address to send reimbursement check,
telephone number and EIN (Employer Idencaon Number) of the holder.
Part II. Claim Informaon: Enter all data necessary to idenfy property for which the holder is
seeking reimbursement. The idencaon data entered on this form must be idencal
to the informaon included on the Report of Abandoned and Unclaimed Property
(AP-2) submied to the Treasury Department. The basic informaon data includes:
1) Report Year.
2) Property Code - the two digit code for the property claimed as dened on the
Summary Sheet of Reported Items (AP-3) or Property Codes (AP-3A).
3) Account/Reference/Check/Number - the idencaon 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 dierent than the owner.
7) Date Paid to Claimant or Date Stock Reissued - the date the claim was paid to
the owner (or his representave) or when the account was reacvated by the
holder, or when the stock cercate was reissued.
8) Amount - the dollar amount or number of shares originally transmied 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 Cercaon: This notarized statement must be completed before Treasury
will process the request for reimbursement and make payment. Proof that the
claimant was paid and entled to the property must be submied with each and
every holder request for reimbursement. Signature must be of a corporate ocer.
INTEREST: The Treasury Department shall pay interest at the prevailing rate for overpayments pursuant
to secon 806.1 of the Fiscal Code. 72 P.S. Secon 1301.14.
AP-5 INSTRUCTIONS