Form Asd-215 - Report Of Unclaimed Securities - North Carolina Department Of State Treasurer

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HOLDER ID# (If Known)
HOLDER NAME
DATE OF INCORPORATION
MAILING ADDRESS
CITY
CONTACT PHONE
STATE OF INCORPORATION
STATE
ZIP CODE
NUMBER OF EMPLOYEES
E-MAIL ADDRESS
-----
FEDERAL IDENTIFICATION NUMBER
Date Certificate(s) sent to BNY Mellon
OWNER RELATIONSHIP CODE
Securities Trust Company, if applicable
SOCIAL SECURITY NUMBER
DATE OF BIRTH
OWNER 1 NAME (LAST, FIRST, MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
OWNER 2 NAME (LAST, FIRST, MIDDLE INITIAL)
ADDRESS
CITY
STATE
ZIP CODE
OWNER(S) EMAIL ADDRESS
OWNER(S) DRIVERS LICENSE NUMBER
ISSUED STATE
ISSUE NAME
TICKER SYMBOL
CUSIP NUMBER
CERTIFICATE NUMBER
NUMBER OF SHARES
Date Certificate(s) sent to BNY Mellon
OWNER RELATIONSHIP CODE
Securities Trust Company, if applicable
SOCIAL SECURITY NUMBER
DATE OF BIRTH
OWNER 1 NAME (LAST, FIRST, MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
OWNER 2 NAME (LAST, FIRST, MIDDLE INITIAL)
ADDRESS
CITY
STATE
ZIP CODE
OWNER(S) EMAIL ADDRESS
OWNER(S) DRIVERS LICENSE NUMBER
ISSUED STATE
ISSUE NAME
TICKER SYMBOL
CUSIP NUMBER
CERTIFICATE NUMBER
NUMBER OF SHARES
Total This Page:
NAME-PRINT:
Report Total:
TITLE:
Enter total number of shares
to be remitted and carry over to ASD-159
SIGNATURE:
REV 08/2015
 
ASD-215

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