Form X-17f-1a - Missing/lost/stolen/counterfeit Securities Report
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3OMB APPROVAL
OMB
Number:
3235-0037
UNITED STATES
Expires: December, 31, 2018
SECURITIES AND EXCHANGE COMMISSION
Estimated average burden
Washington, D.C. 20549
hours per response. . . . . . . 0.08
FORM X-17F-1A
MISSING/LOST/STOLEN/COUNTERFEIT
PLEASE TYPE OR
SECURITIES REPORT
PRINT CLEARLY
1. REPORTING INSTITUTION:
NAME_____________________________________________________________
ADDRESS __________________________________________________________
_________________________________________________ ZIP______________
__________________________________________
ATTENTION: _______________________________________________________
TELEPHONE NO.
FIN/SIC IDENTIFIER NUMBER ___ ___ ___ ___ ___ ___/ (
) (
) (
)
D
D
D
2. TYPE OF REPORT:
LOSS
RECOVERY
UPDATE
3. DATE OF LOSS/RECOVERY ___________________________________
D
D
D
4. TYPE OF LOSS:
MAIL
DELIVERY
ON PREMISES
D
D
CLEARING
OTHER ______________________________
D
D
D
5. TYPE OF SECURITY:
COMMON STOCK
PREFERRED STOCK
CORPORATE BOND
D
D
D
MUNICIPAL BOND
GOVERNMENT/AGENCY
OTHER ______________________________________________
6. NAME OF ISSUER____________________________________________________________________________________________
7. INTEREST RATE __________________________________ 8. MATURITY DATE ___________________________________
9. CUSIP NUMBER ___ ___ ___ ___ ___ ___ ___ ___ ___
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10.
BEARER/NAME OF REGISTERED HOLDER ______________________________________________________________
______________________________________________________________________________________________________________
11. CERTIFICATE/SERIAL NUMBERS
12. DENOMINATION/SHARES
13. ISSUE DATE
___________________________________
_______________________________
_______________________________
___________________________________
_______________________________
_______________________________
___________________________________
_______________________________
_______________________________
___________________________________
_______________________________
_______________________________
D
14.
ADDITIONAL PAGES ATTACHED
15. TOTAL CURRENT MARKET OR FACE VALUE $______________
D
16.
COUNTERFEIT__________________________________________________________________________________________
If counterfeit - Distinguishing Characteristics
D
D
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17.
CRIMINALITY INDICATED REPORTS FILED WITH: 18.
FBI
19.
LOCAL POLICE
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20.
TRANSFER/PAY AGENT____________________________________________________________________________________
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21.
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 displays
SEC 1666 (05-01)
a currently valid OMB control number.
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Parent category: Legal