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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
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