53-119
(Rev.10-17/7)                                                                                                     PRINT FORM RESET FORM
                                                                                                 *5311900W101707*

Texas Unclaimed Property Payment                                                                                        *493134*

                                                            Holder federal employer identification number Core Report ID
                                                            (FEIN)

Holder name and address                                                          State of incorporation or charter

                                                                                 Date of incorporation or charter

                                               Phone number                                                        Phone number
Report Contact                                                    Claims Contact
Name and mailing address                                          Name and mailing address

Email address                                                     Email address

FAX number                                                        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            PAYMENT AMOUNT
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.

If you are paying by check, mail this form with
your payment to
Comptroller of Public Accounts                              For assistance, call 
Unclaimed Property, Holder Reporting Section           1-800-321-2274, option 2.           Title
P.O. Box 12019
Austin, TX  78711-2019

53-119
(Rev.10-17/7)
Payment for Unclaimed Property
     Complete one copy for each check submitted.

1. T code                                                   1.    9 0 1 0 0                     PAYMENT

2. Deposit code                                             2.    5 5 2

3. Federal Employer Identification Number (FEIN)            3.    1

4. Amount of check (Dollars and cents)                      4.                                                    AGENCY USE ONLY
Holder name                                                                                      PM