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Form X-17F-1A Missing-Lost-Stolen-Counterfeit Securities Report (SEC1666) X-17F-1A - Official Federal Forms
| Form X-17F-1A Missing-Lost-Stolen-Counterfeit Securities Report (SEC1666) Form. This is a national form and can be used in Securities And Exchange Commission . |
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 OMB APPROVAL OMB Number: 3235-0037 Expires: December, 31, 2015 Estimated average burden hours per response. . . . . . . 0.08 FORM X-17F-1A PLEASE TYPE OR PRINT CLEARLY MISSING/LOST/STOLEN/COUNTERFEIT SECURITIES REPORT NAME_____________________________________________________________ ADDRESS __________________________________________________________ _________________________________________________ ZIP______________ 1. REPORTING INSTITUTION: __________________________________________ TELEPHONE NO. 2. 3. TYPE OF REPORT: ATTENTION: _______________________________________________________ FIN/SIC IDENTIFIER NUMBER ___ ___ ___ ___ ___ ___/ ( )( )( ) D LOSS D MAIL D CLEARING D RECOVERY D UPDATE DATE OF LOSS/RECOVERY ___________________________________ 4. TYPE OF LOSS: 5. TYPE OF SECURITY: D MUNICIPAL BOND 6. 7. 9. 10. D DELIVERY D ON PREMISES D OTHER ______________________________ D COMMON STOCK D PREFERRED STOCK D CORPORATE BOND D GOVERNMENT/AGENCY DOTHER ______________________________________________ NAME OF ISSUER____________________________________________________________________________________________ INTEREST RATE __________________________________ 8. MATURITY DATE ___________________________________ CUSIP NUMBER ___ ___ ___ ___ ___ ___ ___ ___ ___ D BEARER/NAME OF REGISTERED HOLDER ______________________________________________________________ ______________________________________________________________________________________________________________ 12. DENOMINATION/SHARES _______________________________ _______________________________ _______________________________ _______________________________ 13. ISSUE DATE _______________________________ _______________________________ _______________________________ _______________________________ 11. CERTIFICATE/SERIAL NUMBERS ___________________________________ ___________________________________ ___________________________________ ___________________________________ 14. D ADDITIONAL PAGES ATTACHED 15. TOTAL CURRENT MARKET OR FACE VALUE $______________ If counterfeit - Distinguishing Characteristics 16. D 17. 20. 21. COUNTERFEIT__________________________________________________________________________________________ 19. D CRIMINALITY INDICATED REPORTS FILED WITH: 18. D FBI D LOCAL POLICE D TRANSFER/PAY AGENT____________________________________________________________________________________ D INSURANCE COMPANY__________________________________________________________________________________ 23 ____________________________________________________ Date 22.___________________________________________________ Authorized Signature SEC 1666 (05-01) Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. American LegalNet, Inc. www.FormsWorkFlow.com FORM X-17F-1A INSTRUCTIONS NOTE - Section 240.17f-1 does not require reporting coupons. Municipal or corporate securities not assigned CUSIP Numbers are not the subject of reporting and inquiry. Forms should be mailed to the Commission's designee: Securities Information Center P.O. Box 55151 Boston, MA 02205-5151 1. Reporting Institution -- Enter reporting institution name, address and FINS number, with Securities Information Center assigned suffix, if any. 2. Type of Report -- Check whether report is a new report ("Loss"), report of recovery of previously reported loss ("Recovery"), or update or correction of report other than recovery ("Update"). If the report is an update or correction, attach a copy of the original report. 3. Date -- Enter date when loss was noticed, theft occurred, when counterfeit was discovered or suspected, or when security was found or recovered. When submitting updates, enter date of loss. 4. Type of Loss -- Check the box which most nearly describes the loss. If none of the classifications adequately describes the loss, check "OTHER" and describe the loss in the space provided. 5. Type of Security -- Check the box which most nearly describes the type of security. If none of the classifications adequately describes the security, check "OTHER" and describe the security in the space provided. 6. Issuer -- Print or type the name of issuing company, agency or organization as set out on the security even though the security may have been lost, stolen, or missing prior to being "issued" by the appropriate authority. 7. Interest Rate -- If interest rate was indicated, enter this information. 8. Maturity Date -- Enter maturity date where applicable. 9. CUSIP -- Enter entire CUSIP Number. 10. Name of Registered Holder -- Clearly print or type the full name of person (individual, company, bank, brokerage house, etc.) to whom the security is registered exactly as it appears on the security. Check to indicate "Bearer" when document is a bearer security. 11. Certificate Serial Numbers -- Enter certificate or serial number(s) including all suffixes and prefixes. If certificates have not been issued, enter the control number. Series may be indicated by the first and last numbers separated by a dash and followed by the word "Series." Certificate or serial numbers of certificates of the same CUSIP number, which are not in sequential order should be listed separately on each line. For a non-sequential series of certificates having the same CUSIP number, additional pages listing securities to be reported may be attached. 12. Denomination Shares -- Enter in numerical form the amount of money represented by bonds, debentures, notes and other securities (except stock warrants and rights) as indicated on the certificates. If amount was not indicated on the certificate, enter the word, "Blank." For stocks, enter the number of shares represented by the certificates, not the par value of the stock. If number of shares is not represented, enter the word "Blank." For warrants and rights, enter in numerical form the number of shares which the document entitles the owner to purchase. 13. Issue Date -- Enter issue date of certificate. If certificates have not yet been issued, indicate this fact. 14. Additional Pages -- If additional pages are attached, check the box. 15. Total Current Market or Face Value -- For stocks, rights and warrants, enter the approximate total current market value. For bonds, enter the face value of the certificate. 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 16. Counterfeit -- Desc
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