Enlarge image | 53-119 PRINT FORM RESET FORM (Rev.2-16/6) *5311900W021606* AGENCY USE ONLY Holder federal employer identification number Div Year Seq Type Texas Unclaimed Property Payment (FEIN) Holder name and address State of incorporation or charter Date of incorporation or charter Phone number Phone number Report Contact Claims Contact Name Name Mailing address Mailing address Email address Email address FAX number FAX number Holder's primary business activity: SIC code: Circle all report media used and provide report totals. NUMBER Confirmation number must be included if filing via Internet OF ITEMS SHARES CASH Diskette / CD $ (CD or Diskette submission requires prior approval from CPA staff.) Internet (Transmission confirmation number E ) $ 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. 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 * * * DO NOT DETACH * * * 53-119 (Rev.2-16/6) 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 |