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