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Form X-17F-1A Missing-Lost-Stolen-Counterfeit Securities Report (SEC1666) Form. This is a Official Federal Forms form and can be use in Securities And Exchange Commission.
Tags: Form X-17F-1A Missing-Lost-Stolen-Counterfeit Securities Report (SEC1666), X-17F-1A, Official Federal Forms Securities And Exchange Commission,
UNITED STATES002 SECURITIES AND EXCHANGE COMMISSION002 OMB APPROVAL OMB Number: 3235-0037 Expires: , 20 Estimated average burden hours per response. . . . . . . 0.08 PLEASE TYPE OR PRINT CLEARLY 1.REPORTING INSTITUTION:TELEPHONE NO.2.TYPE OF REPORT:001 LOSS Washington, D.C. 20549 FORM X-17F-1A MISSING/LOST/STOLEN/COUNTERFEIT SECURITIES REPORT NAME ADDRESS ZIP ATTENTION: FIN/SIC IDENTIFIER NUMBER / ( ) ( ) ( ) 001 RECOVERY 001 UPDATE 3.DATE OF LOSS/RECOVERY 4.TYPE OF LOSS:001 MAIL 001 DELIVERY 001 ON PREMISES 001 CLEARING 001 OTHER 5.TYPE OF SECURITY:001 COMMON STOCK 001 PREFERRED STOCK 001 CORPORATE BOND 001 MUNICIPAL BOND001 GOVERNMENT/AGENCY 001OTHER 6.NAME OF ISSUER 7.INTEREST RATE 8. MATURITY DATE 9.CUSIP NUMBER 003 10.001 BEARER/NAME OF REGISTERED HOLDER 11.CERTIFICATE/SERIAL NUMBERS12.DENOMINATION/SHARES13.ISSUE DATE14.001 ADDITIONAL PAGES ATTACHED15.TOTAL CURRENT MARKET OR FACE VALUE $16.001 COUNTERFEIT If counterfeit -Distinguishing Characteristics 17.001 CRIMINALITY INDICATED REPORTS FILED WITH: 18.001 FBI 19.001 LOCAL POLICE20.001 TRANSFER/PAY AGENT 21.001 INSURANCE COMPANY 22. 23 Authorized Signature Date Persons who respond to the collection of information contained in this form are not required to respond unless the form displaysSEC 1666 (05-01) a currently valid OMB control number. American LegalNet, Inc. www.FormsWorkFlow.com FORM X-17F-1A002 INSTRUCTIONS002 NOTE -Section 240.17f-1 does not require reporting coupons. Municipal or corporate securities not assigned CUSIP Numbers are not the subject of reporting and inquiry. Forms should be mailed to the Commission222s designee: Securities Information Center P.O. Box 55151001 Boston, MA 02205-5151001 1. 003Reporting Institution 227 Enter reporting institution name, address and FINS number, with Securities Information Center assigned suffix, if any. 2. Type of Report 227 Check whether report is a new report (223Loss224), report of recovery of previously reported loss (223Recovery224), or update or correction of report other than recovery (223Update224). If the report is an update or correction, attach a copy of the original report. 3. 003Date 227 Enter date when loss was noticed, theft occurred, when counterfeit was discovered or suspected, or when security was found or recovered. When submitting updates, enter date of loss. 4. 003Type of Loss 227 Check the box which most nearly describes the loss. If none of the classifications adequately describes the loss, check 223OTHER224 and describe the loss in the space provided. 5. Type of Security 227 Check the box which most nearly describes the type of security. If none of the classifications adequately describes the security, check 223OTHER224 and describe the security in the space provided. 6. Issuer 227 Print or type the name of issuing company, agency or organization as set out on the security even though the security may have been lost, stolen, or missing prior to being 223issued224 by the appropriate authority. 7. Interest Rate 227 If interest rate was indicated, enter this information. 8. Maturity Date 227 Enter maturity date where applicable. 9. CUSIP 227 Enter entire CUSIP Number. 10. 003Name of Registered Holder 227 Clearly print or type the full name of person (individual, company, bank, brokerage house, etc.) to whom the security is registered exactly as it appears on the security. Check to indicate 223Bearer224 when document is a bearer security. 11. Certificate Serial Numbers 227 Enter certificate or serial number(s) including all suffixes and prefixes. If certificates have not been issued, enter the control number. Series may be indicated by the first and last numbers separated by a dash and followed by the word 223Series.224 Certificate or serial numbers of certificates of the same CUSIP number, which are not in sequential order should be listed separately on each line. For a non-sequential series of certificates having the same CUSIP number, additional pages listing securities to be reported may be attached. 12. 003Denomination Shares 227 Enter in numerical form the amount of money represented by bonds, debentures, notes and other securities (except stock warrants and rights) as indicated on the certificates. If amount was not indicated on the certificate, enter the word, 223Blank.224 For stocks, enter the number of shares represented by the certificates, not the par value of the stock. 003If number of shares is not represented, enter the word 223Blank.224 For warrants and rights, enter in numerical form the number of shares which the document entitles the owner to purchase. 13. 003Issue Date 227 Enter issue date of certificate. If certificates have not yet been issued, indicate this fact. 14. 003Additional Pages 227 If additional pages are attached, check the box. 15. 003Total Current Market or Face Value 227 For stocks, rights and warrants, enter the approximate total current market value. For bonds, enter the face value of the certificate. 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 16. Counterfeit 227 Describe distinguishing characteristics of suspected counterfeit securities. 17. Criminality Indicated 227 If reporting a loss, check when a substantial belief of criminality is indicated. 18. Filed with Federal Bureau of Investigation 227 Check if you sent a copy of this report to the FBI when required. 19. Filed with Local Police 227 Check if you sent a copy of this report to the local police when required. 20. Transfer/Pay Agent 227 Check to indicate that you sent a copy of this report to a Transfer or Paying Agent for the issue, and enter the name and address. 21. Insurance Co .227 Check to indicate that you have sent a copy of this report to your insurance company, and enter the name and address. 22. Authorized Signature 227 Form X-17F-1A must have an authorized signature to be accepted by the System. With respect to those reports filed with the Commission222s designee, such signatures must be on file with the designee. Copies of reports sent to the transfer agent and the appropriate law enforcement agency should contain an original signature. 23. Date 227 Enter date when form is signed. NOTE 227 This form may be reproduced in any manner so long as the graphics and format are not altered and 8.5224 x 11224 paper is used. 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com