RPD-41204
Rev. 04/02/2014
                                State of New Mexico - Taxation & Revenue Department

                          LIST OF UNCLAIMED CONTENTS OF SAFE DEPOSIT BOXES 
Page No._____ of ______   OR OTHER SAFEKEEPING REPOSITORIES
Holder (Name of Business)                                                                      Report Year                            Federal ID Number

Address                                                                                                                     Period Covered

City                      State                                             ZIP Code           From: ________________________                   To: ____________________________
                                                                                                             (MM/DD/YY)                                              (MM/DD/YY)
Contact Name                    Daytime Phone Number                                           E-mail Address

               Owner Name                                                   Last Known Address Social Security No.  Safe Deposit Box  No.  Description of Articles
Last                                 First                           Middle Number & Street    or Federal Tax ID  or Identifying No.  of 
                                                                            City, State, ZIP   No.                                    Items
               (1)                                                          (2)                (3)                      (4)           (5)              (6)

                                                                                                           :  No. of Items:  List the number of items.Column 5

     (505) 827-0767 or (505) 827-0668                                                                                 box or other safekeeping identification number.
                                                                                         : Safe Deposit Box or Identifying No.:  Enter the safe deposit     Column  4
     Santa Fe, New Mexico 87504-5123
            P O Box 25123                                                                                                 ID Number (if business).
     Unclaimed Property Office                                                           Security Number of each owner of the funds or Federal Tax                    
 New Mexico Taxation & Revenue Department                                                : Social Security No. or Federal Tax ID No.: Enter Social                                                                           Column 3

            contact the Unclaimed Property Office at:                                    such address. If the address is unknown, enter “Unknown”.
If you have any questions concerning your reporting obligations, please                  on your records, even though mail has been returned from                                                                            
                                                                                         :  Last Known Address:  Enter last known address of the owner                               Column 2
.You may photocopy this form as needed to complete your annual report
                                                                                                                          able, enter “Unknown”.
                       Unclaimed Property Office.                                        both names within the same block. If owner name is unavail-
NOTE:  When addressing, specify the attention of the to verify delivery.                 owner’s name. If there is joint ownership of the securities, list 
you choose to use the U.S. Postal Service, be sure to request return receipt             first name, middle name or initial. Use one block for each 
We suggest you deliver your safe deposit box contents by courier service. If             : Owner Name (list alphabetically): Enter owner’s last name,         Column 1

 If there are no contents in the box, do not report owner information.                   eral Tax ID Number, contact person, phone number and E-mail address.
                                                                                         of the form to include: name, address, reporting year, period covered, Fed-
 recorded. Example: 10 (ten) $1.00 (one dollar) bills = $10.00.                          : Complete the holder information on the top HOLDER INFORMATION
cording to monetary denomination, with the total cash value 
shares. If reporting currency (foreign and domestic), list ac-                                    unclaimed property under Section [7-8A-3-NMSA 1978].
the registered owner’s name, issuing company and number of                               Office with an inventory of property in its possession which constitutes 
reportable items found in the box. If reporting stock, include                           tories in the State of New Mexico shall report to the Unclaimed Property 
: Description of Articles:  Enter a complete description of all                 Column 6 Every holder maintaining safe deposit boxes or other safekeeping reposi-

 OF SAFE DEPOSIT BOXES OR OTHER SAFEKEEPING REPOSITORIES

            INSTRUCTIONS FOR LIST OF UNCLAIMED CONTENTS
                                                                                                                                                                                                                             Rev. 04/02/2014
                                                                                                                                                                                                                             RPD-41204