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, 20 , 20 Country if Not USA Country if Not USA Country if Not USA Country if Not USA Country if Not USA
Page _______ of _______ Page _______ of _______
State (2) Zip (9) State (2) Zip (9) State (2) Zip (9) State (2) Zip (9) State (2) Zip (9)
P Otherwise R Owner Claimed Reduced to Zero Yes P Otherwise R Owner Claimed Reduced to Zero Yes P Otherwise R Owner Claimed Reduced to Zero Yes P Otherwise R Owner Claimed Reduced to Zero Yes P Otherwise R Owner Claimed Reduced to Zero Yes
Escheated Amount Removal Indicator (If Applicable, Enter “P” or “R”) Multiple Owners $ CUSIP Number of Security No. of Shares or Denomination Method of Transfer Escheated Amount Removal Indicator (If Applicable, Enter “P” or “R”) Multiple Owners $ CUSIP Number of Security No. of Shares or Denomination Method of Transfer Escheated Amount Removal Indicator (If Applicable, Enter “P” or “R” ) Multiple Owners $ CUSIP Number of Security No. of Shares or Denomination Method of Transfer Escheated Amount Removal Indicator (If Applicable, Enter “P” or “R”) Multiple Owners $ CUSIP Number of Security No. of Shares or Denomination Method of Transfer Escheated Amount Removal Indicator (If Applicable, Enter “P” or “R”) Multiple Owners $ CUSIP Number of Security No. of Shares or Denomination Method of Transfer
Owner City (20) Owner City (20) Owner City (20) Owner City (20) Owner City (20)
$ $ $ $ $
Date (MMDDYY) Initial Amount Date (MMDDYY) Initial Amount Date (MMDDYY) Initial Amount Date (MMDDYY) Initial Amount
Date (MMDDYY) Initial Amount
M.I. Suffix (3) Account Title (70) M.I. Suffix (3) Account Title (70) M.I. Suffix (3) Account Title (70) M.I. Suffix (3) Account Title (70) M.I. Suffix (3) Account Title (70)
Owner Address 2 (30) Owner Address 2 (30) Owner Address 2 (30) Owner Address 2 (30) Owner Address 2 (30)
REPORT OF ABANDONED PROPERTY REPORT OF ABANDONED PROPERTY
First Name (10) First Name (10) First Name (10) First Name (10)
First Name (10)
Owner Address 1 (30) Owner Address 1 (30) Owner Address 1 (30) Owner Address 1 (30) Owner Address 1 (30)
No. No. Soc. Sec. No./Empl. ID No. Property Type (2) Property ID Number (20) Description of Security (70) 2 Soc. Sec. No./Empl. ID No. Property Type (2) Property ID Number (20) Description of Security (70) Soc. Sec. No./Empl. ID No. Property Type (2) Property ID Number (20) Description of Security (70) Soc. Sec. No./Empl. ID No. Property Type (2) Property ID Number (20) Description of Security (70) Soc. Sec. No./Empl. ID No. Property Type (2) Property ID Number (20) Description of Security (70)
1 3 4 5
No. No. No. No. No.
Reg. Reg. Reg. Reg. Reg.
Owner Last Name (20) Lot Owner Last Name (20) Lot Owner Last Name (20) Lot Owner Last Name (20) Lot Owner Last Name (20) Lot
AC 2686 (1/02) STATE OF NEW YORK – OFFICE OF THE STATE COMPTROLLER – AC 2686 (1/02) STATE OF NEW YORK – OFFICE OF THE STATE COMPTROLLER – Do Not Write in This Area Rec Name of Reporting Organization Address of Reporting Organization City State Zip For The Period Ending Do Not Write in This Area Rec Name of Reporting Organization Address of Reporting Organization City State Zip For The Period Ending OUF USE ONLY OUF USE ONLY
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