Unclaimed Property Owners Security Form

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.
_ _ _ _ _ _ _
SHARES
---- -- -
_ _ _ _ _
_ _ _ _ _
-
This form can only be used by entities reporting
U NCLA
ED PROPERTY OWNERS
five or fewer property records.
MINNESOTA
DEPARTMENT
OF
COMMERCE
Contact department for current number.
A. HOLDER NAME
DEPOSIT TO: DTC ACCOU NT #
B. TAXID#
C. MN HOLDER ID#
D. REPORT YEAR
E. PAGE
OF
__
__
__
I.
Owner Name
2.
Last Known Address
3. Social Security
4. Property
S. CUSIP
6.
Last Activity
7. Remitted
[Last, first, Middle Initial]
[Street, City, State, Zip]
Number
Code
Number
Date
Shares
H. PAGE TOTAL
F. NUMBER DTC/PHYSICAL SHARES
G. NUMBER DRP/STATEMENT
(last page
A computer printout with the above-noted information is acceptable
I. REPORT TOTAL
only)
UP-S 000800

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