Form X-17f-1a - Missing/lost/stolen/counterfeit Securities Report Page 3
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316. 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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