To Report Securities See Report Year 2010 Form - State Of South Carolina (Page 3 of 5) in pdf

To Report Securities See Report Year 2010 Form - State Of South Carolina Page 3

STATE OF SOUTH CAROLINA

LIST OF OWNERS OF UNCLAIMED FUNDS

SECURITIES

THIS REPORT SHOULD CONTAIN ONLY SECURITIES AND THOSE DIVIDENDS REPORTABLE WITH THE SHARES

TO REPORT CASH ITEMS SEE PAGE 9

REPORT YEAR 2010

HOLDER INFORMATION:

COMPANY NAME:__________________________________________

FEDERAL TAX ID# :_______________________________

ADDRESS:_________________________________________________

CONTACT PERSON:_______________________________

__________________________________________________

PHONE NUMBER:______________________________

STATE OF INCORPORATION _______________________________

E-MAIL ADDRESS:______________________________

DID YOUR COMPANY FILE UNDER A DIFFERENT NAME LAST YEAR? IF SO, PRINT COMPANY NAME_____________________________________

PROPERTY

OWNER

LAST KNOWN ADDRESS:

SOCIAL

LAST

CODE &

CODE

NAME: LAST,

SECURITY

STREET CITY, STATE,

SECURITY # OR

ACTIVITY

RELATION

CUSIP

DIVIDENDS

(See page 5)

FIRST,

NAME

CODE

ZIP

TAX ID

DATE

MIDDLE

(

See page 5)

PAGE TOTALS:

# __________ $___________

IF YOU ARE REPORTING MORE THAN FIVE INDIVIDUAL ITEMS, PLEASE DO SO USING THE FREE EASY TO

USE REPORTING SOFTWARE. SEE PAGE 15 FOR DOWNLOAD INSTRUCTIONS.

11 11

To Report Securities See Report Year 2010 Form - State Of South Carolina Page 3

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