Form Up-3s - Securities Dtc Transfer Confirmation
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1UP-3S(Rev. 01/17)
GEORGIA DEPARTMENT OF REVENUE
UNCLAIMED PROPERTY PROGRAM
SECURITIES DTC TRANSFER CONFIRMATION
FORM UP-3S
This form must accompany all holder reports
if you are reporting securities
Page ______ of _______
HOLDER NAME
ADDRESS
DTC #
FEIN
GA HOLDER ID # (1)
HOLDER REPORT DATE (2)
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, Wells Fargo Advisors. State reporting requirements mandate the transfer of all eligible
shares using DTC. Specific instructions for completing this form and transferring the shares can be found in the accompanying
“Instructions for Completion of Form UP-3S.”
TOTAL SHARES
DTC TRANSFER
STOCK ISSUE NAME
CUSIP #
TRANSFERRED
DATE
(4)
(3)
(5)
(6)
I, the undersigned, certify that the securities listed above have been successfully transferred via DTC to Wells Fargo Advisors,
custodian for The State of Georgia on the date(s) indicated.
Signed ___________________________________
Title ________________________________
Date ___________________________________
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