Form Up-3s - Securities Dtc Transfer Confirmation - 2012
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1UP-3S(Rev. 06/2012)
GEORGIA DEPARTMENT OF REVENUE
UNCLAIMED PROPERTY PROGRAM
2012 SECURITIES DTC TRANSFER CONFIRMATION
FORM UP-3S
This form must accompany all holder reports.
Page ______ of _______
HOLDER NAME
ADDRESS
FEIN
HOLDER REPORT DATE (2)
GA HOLDER ID # (1)
This form is used to notify the Georgia Unclaimed Property Program that all securities reported as unclaimed property have
been transferred to the state’s custodian, Merrill Lynch. New state reporting requirements mandate the transfer of all eligible
shares using DTC. Specific instructions for completing this form and transfering the shares can be found in the accompanying
“Instructions for Completion of Form UP-3S.”
DTC TRANSFER
TOTAL SHARES
STOCK SYMBOL
CUSIP #
STOCK ISSUE NAME
DATE
TRANSFERRED
(4)
(5)
(7)
(3)
(6)
GRAND TOTAL OF SHARES TRANSFERRED (8)
I, the undersigned, certify that the securities listed above have been successfully transferred via DTC to Merrill Lynch, custodian
for The State of Georgia on the date(s) indicated.
Signed ___________________________________
Title ________________________________
Date ______________________
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