Form X-17F-1A Form X-17F-1A Reporting of missing, lost, stolen or counterfeit securi

UNITED STATES

SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

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FORM X-17F-1A
MISSING/LOST/STOLEN/COUNTERFEIT
SECURITIES REPORT

PLEASE TYPE OR
PRINT CLEARLY

1.

REPORTING INSTITUTION:

NAME_____________________________________________________________
ADDRESS __________________________________________________________
_________________________________________________ ZIP______________

__________________________________________
TELEPHONE NO.

ATTENTION: _______________________________________________________
FIN/SIC IDENTIFIER NUMBER ___ ___ ___ ___ ___ ___/ (

D LOSS

D RECOVERY

2.

TYPE OF REPORT:

3.

DATE OF LOSS/RECOVERY ___________________________________

D MAIL
D CLEARING

4. TYPE OF LOSS:
5. TYPE OF SECURITY:
D MUNICIPAL BOND

)(

)(

)

D UPDATE

D DELIVERY
D ON PREMISES
D OTHER ______________________________

D COMMON STOCK
D PREFERRED STOCK D CORPORATE BOND
D GOVERNMENT/AGENCY DOTHER ______________________________________________

6.

NAME OF ISSUER____________________________________________________________________________________________

7.

INTEREST RATE __________________________________ 8. MATURITY DATE ___________________________________

9.

CUSIP NUMBER ___ ___ ___ ___ ___ ___ ___ ___ ___

10.

D BEARER/NAME OF REGISTERED HOLDER ______________________________________________________________
______________________________________________________________________________________________________________

11. CERTIFICATE/SERIAL NUMBERS
___________________________________
___________________________________
___________________________________
___________________________________
14.

D ADDITIONAL PAGES ATTACHED

16. D

12. DENOMINATION/SHARES
_______________________________
_______________________________
_______________________________
_______________________________

13. ISSUE DATE
_______________________________
_______________________________
_______________________________
_______________________________

15. TOTAL CURRENT MARKET OR FACE VALUE $______________

COUNTERFEIT__________________________________________________________________________________________
If counterfeit - Distinguishing Characteristics

17.

D CRIMINALITY INDICATED REPORTS FILED WITH: 18. D FBI

20.

D TRANSFER/PAY AGENT____________________________________________________________________________________

21.

D INSURANCE COMPANY__________________________________________________________________________________

22.___________________________________________________
Authorized Signature

SEC 1666 (05-01)

19.

D LOCAL POLICE

23 ____________________________________________________
Date

Persons who respond to the collection of information contained
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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.
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16. Counterfeit — Describe distinguishing characteristics of suspected counterfeit securities.
17. Criminality Indicated — If reporting a loss, check when a substantial belief of criminality is indicated.
18. Filed with Federal Bureau of Investigation — Check if you sent a copy of this report to the FBI when required.
19. Filed with Local Police — Check if you sent a copy of this report to the local police when required.
20. Transfer/Pay Agent — Check to indicate that you sent a copy of this report to a Transfer or Paying Agent for the issue, and
enter the name and address.
21. Insurance Co .— Check to indicate that you have sent a copy of this report to your insurance company, and enter the name
and address.
22. Authorized Signature — Form X-17F-1A must have an authorized signature to be accepted by the System. With respect
to those reports filed with the Commission’s designee, such signatures must be on file with the designee. Copies of reports
sent to the transfer agent and the appropriate law enforcement agency should contain an original signature.
23. Date — Enter date when form is signed.
NOTE — This form may be reproduced in any manner so long as the graphics and format are not altered and 8.5” x 11” paper
is used.

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