*5311900W101707* Texas Unclaimed Property …
53-119 (Rev.10-17/7)
*5311PR9IN0T F0ORWM10RE1SE7T 0FO7RM*
Texas Unclaimed Property Payment
Holder federal employer identification number (FEIN)
*493134*
Core Report ID
Holder name and address
State of incorporation or charter Date of incorporation or charter
Report Contact
Name and mailing address
Phone number
Claims Contact
Name and mailing address
Phone number
Email address FAX number
Email address FAX number
Please provide report totals.
NUMBER OF ITEMS
SHARES
CASH
$
The foregoing report contains a full and complete list of all property held by the undersigned that from the records of the undersigned, is abandoned under the laws of the State of Texas.
The property delivered is a complete and correct remittance of all accounts; the existence and location of the listed owners are unknown; and the listed owners have not asserted an act of ownership with respect to the reported property.
PAYMENT AMOUNT
$
If you are paying by check, mail this form with your payment to
Comptroller of Public Accounts Unclaimed Property, Holder Reporting Section P.O. Box 12019 Austin, TX 78711-2019
For assistance, call
1-800-321-2274, option 2.
Title
53-119 (Rev.10-17/7)
Payment for Unclaimed Property
Complete one copy for each check submitted.
1. T code
2. Deposit code
3. Federal Employer Identification Number (FEIN)
1. 9 0 1 0 0 2. 5 5 2 3. 1
4. Amount of check (Dollars and cents)
4.
Holder name
PAYMENT PM
AGENCY USE ONLY
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