53-118
(Rev.2-16/3)

Payment for Unclaimed Property
Complete one copy for each check submitted.

                                       Detach and mail the form below along with your payment(s) to

                                       TEXAS STATE COMPTROLLER OF PUBLIC ACCOUNTS
                                                                                       Unclaimed Property Division
                                                                                         P.O. Box 12019
                                                                                       Austin, TX  78711-2019

                                       For assistance, call 1-800-321-2274, option 2.

                    Detach and send only the copy below to the Comptroller's office.
#                                                                                                                                                         #

53-118                                                                                                            *5311801W021603*PRINT FORM RESET FORM
(Rev.2-16/3)                                                                                      2.              *5311801W021603*
                                                                                                                    *   5   3 1 1    8 0 1 W 0          2 1 6 0 3 *
Payment for Unclaimed Property
Complete one copy for each check submitted.                                                                       Shaded areas for Comptroller use only.
1.  T code ........................................................................ 1.  9 0 1 0 0    PAYMENT

                                                                                                       UNCLAIMED PROPERTY DEPOSIT CODES
3.  Deposit code .............................................................. 3.      5  5 551 - Accruing stock dividends   553 - Ongoing mineral production
                                                                                             552 - Annual holder report       556 - Interest and penalty

4.  Federal Employer Identification Number (FEIN) ........ 4.                           1

5.  Amount of check (Dollars and cents)  ........................ 5.
Holder name                                                                                                             Postmark date