DFS-UP-128                                                   STATE OF FLORIDA 
                                  ANNUAL REPORT OF PROPERTY PRESUMED ABANDONED             
                                   FOR SECURITIES THAT CANNOT BE LIQUIDATED 
MAIL TO:                                                        
                                   PURSUANT TO THE FLORIDA DISPOSITION OF UNCLAIMED PROPERTY  
State of Florida                                 CHAPTER 717, FLORIDA STATUTES   
Department of Financial Services 
Bureau of Unclaimed Property  
P.O Box 6350                       Covering UNCLAIMED ITEMS as of          December 31, ___________ 
Tallahassee, FL 32314-6350 
(850) 413-5522                     UPID Number (From DFS-UP-111 Cover Sheet) __________________ 
                                    
                                   Federal Tax Identification Number   (FEIN) ________________________             
                                                                                                                            
 NUMBER OF          NAME and LAST KNOWN ADDRESS               SSN/FEIN PROPERTY                         DATE      ACCOUNT  ISSUE OF 
 SHARES              (Street, City & State) date of birth of OF OWNER         TYPE                       OF LAST  NUMBER   STOCK AND 
 REPORTED                     owner(s) including                               CODE                     TRANS-              CUSIP 
                         all joint/alternate owners,                                                    ACTION             NUMBER  
                        beneficiaries, and relationship 
                                       LAST NAME FIRST 
                                                                                                                           
___________ PAGE TOTAL 
Effective Date 2-12-97 
Rule 69I-20.034, F.A.C. 

                                  DFS-UP-128 FOR SECURITIES 
This form is used to list the ‘Securities” related property (preferred stock, bonds, debentures, or mutual 
funds) due for owners.  The remittance for these items is due at the same time as you submit your 
unclaimed property report.       
REMINDER:  The Department forms cannot be used if your unclaimed property report includes 25 
or more owners.   

DFS-UP-128  FORM  ETAILD          
  A. Column   “NUMBER OF SHARES REPORTED                     ” - Enter the sum of the shares, by issue, due the 
      owner.  Multiple issues for the same owner will require separate entries on the form. 
   
  B. Column “    NAME AND LAST KNOWN ADDRESS                     ” – Enter the last name, first name and full 
      middle name, if available.  Corporate or other titles must be entered exactly as adopted, except the 
      word “the” must be omitted when it is the first word in the name.  If the owner name is not known, 
      insert “Unknown” as the owner name.  List the last known address, including zip code of the 
      owner as it last appeared in the holder’s records.  Include the address, even when the address is 
      incomplete or erroneous.  If no address is available, insert “Address Unknown” beneath the name.  
      If the property has more than one owner, the names and addresses of the alternate owners must be 
      listed beneath the original owner’s name.  If there is no alternate owner for this account, then the 
      wording “No Alternate Owner” must be entered after each account.   
 
      1.      The relationship between the owners must also be shown (A list of valid relationship 
              codes can be found in the RELATIONSHIP CODE TABLE).  Enter the date of birth, if 
              available.  Reports that do not meet this requirement will be returned to the holder to 
              supply the omitted information and are subject to potential fines and interest penalties.   
 
  C. Column “    SSN/FEIN OF OWNER      ” – Enter the social security number of the individual or FEIN 
      for the business of the reported owner of the property.  Social security numbers must be reported 
      for securities holdings.  If the alternate owner’s SSN is available, it must also be reported.  If no 
      social security number is available, insert “Unknown” in this column.  Common abbreviations are 
      SSN, FEID, EIN, and TIN.  The SSN/FEIN number is required information that must be included 
      on the report. 
 
  D. Column “    PROPERTY TYPE CODE         ” - Enter the property type code of each item.  The property 
      type codes are listed in the FLORIDA PROPERTY CODE AND DORMANCY TABLE.  
      Select the 4-character code that best describes the property being reported.  The valid codes for 
      securities are SC08, SC10, SC11, SC14, SC15, SC16, SC17, SC19 and DM02.  The property type 
      code is required information that must be included on the report. 
 
  E. Column “    DATE OF LAST TRANSACTION             ” - Enter the date the property became payable, 
      redeemable or returnable.  This is the date a dividend became payable, the date of last 
      communication with the owner, or the date that statements and mailings are being returned as 
      undeliverable.  The date of last transaction is required information that must be included on the 
      report. 
 
 The Date of Last Transaction is not the date of the holder’s due diligence letter.  
 Make sure that all reported accounts have reached the end of their statutory 
 dormancy period. 
  

 F. Column “ACCOUNT NUMBER” - Enter the identifying number of each item such as check 
    number, account number, employee number, etc.  This number is not the holder number or FEIN.  
    The account number is required information that must be included on the report. 
  
 G. Column “ISSUE OF STOCK AND CUSIP NUMBER” - The issue name as shown on the 
    certificate including series designation and the CUSIP number for each issue.  The stock issue 
    name and CUSIP number is required information that must be included on the report. 
 
 ALL of the columns on the form must be completed.  Any incomplete forms 
 will be recorded as non-compliant and will be returned to the holder to correct.  
 Information not known must be marked as “Unknown”.