Form Up-1s - Holder Report Summary - Securities And Securities Related Cash - 2013
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1UP-1S (Rev. 06/2013)
GEORGIA DEPARTMENT OF REVENUE
UNCLAIMED PROPERTY PROGRAM
2013 HOLDER REPORT SUMMARY
FORM UP-1S
SECURITIES AND SECURITIES RELATED CASH
This form must accompany all holder reports
DID YOU ATTACH A CD? Y [ ] N [ ] ELECTRONIC FILERS: Submit a UP-1S for each business included on the CD.
Transfer all securities to Wells Fargo Advisors (see instructions for UP-3S)
HOLDER INFORMATION
1. FEDERAL EMPLOYER ID#
2. HOLDER (Business Name)
ADDRESS
CITY, STATE, ZIP CODE
3. IS THIS REPORT BEING PREPARED BY AN AGENT ON BEHALF OF THE HOLDER?
Y [
]
N [
]
IF YES, FURNISH AGENT NAME
AND ADDRESS:
5. TELEPHONE
4. NAME OF CONTACT PERSON
6. E-MAIL ADDRESS
(
)
7. DATE OF INCORPORATION
8. STATE OF INCORPORATION
REPORT INFORMATION
Delivery and registration of shares remitted (see instructions)
STOCK
MUTUAL FUNDS
9A. Total - properties reported
_____________________
10A. Total - properties reported
________________
9B. Total - physical shares
_____________________
10B. Total - DTC shares
_____________________
9C. Total - DTC shares
______________________
10C. Total - book shares/DRP
_____________________
9D. Total - securities related - cash remitted _____________________
10D. Total - securities related - cash remitted _____________________
9E. Total - stock remitted B+C
_____________________
10E. Total - stock remitted B+C
_____________________
ENCLOSE CONFIRMATION OF DELIVERY OF SHARES AND MUTUAL FUND STATEMENTS
VERIFICATION STATEMENT
I,
certify that I have caused to be prepared and have examined this report
totaling ____________ shares and $________________ as to property presumed abandoned under the “Disposition of
Unclaimed Property Act” for the year ended as stated, that I am duly authorized to execute this verification by the holder and
that I believe said report to be true, correct and complete as of said date to the best of my knowledge.
Signature of Responsible Officer
Printed or Typed Name of Responsible Officer
Title of Responsible Officer
Date
FOR OFFICE USE ONLY
CD?
CHECK NUMBER
CHECK DATE
CHECK AMOUNT
DATE DEPOSITED
BATCH NO.
RECEIPT NO.
REPORT ID
HOLDER NO.
STOCK BATCH ID
STOCK RECEIPT ID
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