Stock And Mutual Fund Reporting Form - Nebraska Unclaimed Property Division
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2Stock and Mutual Fund Reporting Form
<<< THIS PAGE MUST BE INCLUDED IF YOUR REPORT INCLUDES SHARES OF STOCK OR MUTUAL FUNDS >>>
Transfer shares into the State of Nebraska’s account at UBS Financial Services. All shares need to be registered
under the name, Nebraska State Treasurer’s Office.
• Only remit shares for Nebraska owners.
• Do not remit fractional shares of stock. Liquidate fractional shares and remit the proceeds.
• Dividends and capital gains must be paid in cash only. No new shares should be reinvested
in State of Nebraska accounts once reported November 1 or May 1. The number of shares
remitted must match the number of shares listed on your unclaimed property report.
MAILING ADDRESS:
Nebraska State Treasurer
FEIN: 47-0491233
Unclaimed Property Division
DTC: 0221
809 P Street
ACCOUNT NUMBER: VS 67641
Lincoln, NE 68508-1390
STOCK
Name of Security:
CUSIP:
SYMBOL:
Number of Shares:
Date stock will be transferred to the State Treasurer’s Office:
Contact Person for Report:
Phone:
Form shares will be transferred:
DTC Physical Certificate Book Entry (List Account #):
Other (Please explain):
If your report includes more than one security, please use the template provided at the following address:
Please email a copy of this form to the following email address before your report is remitted to the
Unclaimed Property Division:
nst.upsecurities@nebraska.gov
Thank you.
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