RPD-41205         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

                  HOLDER'S NEGATIVE REPORT

Name of Holder

Address

City                                              State              ZIP Code

Federal ID Number                                 Telephone Number
                                                  (       )
E-mail Addresss

The above named holder has no unclaimed property to file with the State of New 
Mexico for the ____________ Annual Report Year of the Period Ending June 30, 
____________.

I declare that I have examined this report and, to the best of my knowlege and 
belief, it is true, correct and complete.

Printed Name                                      Title

Signature                                         Date