RPD-41201            State of New Mexico - Taxation & Revenue Department
Rev. 07/15/2016
                                        Unclaimed Property Office
                                        P.O. Box 25123
                                    Santa Fe, New Mexico 87504-5123
                                    (505) 827-0762 or (505) 827-0668

                     New Mexico Report of Unclaimed Property

               File on or before November 1 (May 1 for life insurance). If the due date falls on a weekend or holiday, 
                     the report is due the next business day and becomes delinquent on the first day thereafter.

PLEASE CHECK ONE:        First Filing   Annual Report 20__       Verification for Period Ended ______, 20__
                         Amended        Safety Deposit Boxes     Supplemental
Name of Holder

Address

City

Contact Person                                                      State                   ZIP Code

Federal ID Number                                                   Telephone Number
                                                                    (          )
Do any other departments, branches, or subsidiaries file reports using this same ID Number? Yes                 No

Primary Business Activity

Did you file a report of Unclaimed Property last year?  Yes         No

If no, please explain

If you are a successor, list the name(s) and Federal ID Number(s) of all previous holders of the property. If you have 
changed your name during the time in which you held the property, list the prior name(s), state of incorporation, date the 
corporation changed names and Federal ID Number(s)

               Your remittance and confirmation of shares transferred into New Mexico 
                         (if applicable) must  accompany  this report.

                                        Total amount due from last page  $
    Stock sent  to Mellon Security Trust
                                        Penalty
    Copy of Stock
                                        Interest
Cusip Number                            Total Remittance
Number of Shares                        Total Number of Share

                                    OFFICIAL VERIFICATION REPORT
I declare that I have examined this return and the information reported on this form and attached schedules is true and 
correct as to every material matter.
Printed Name                                            Title

Signature                               Date                     E-mail address