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RPD-41201
Rev.03/23/2022 State of New Mexico - Taxation & Revenue Department
Unclaimed Property Office
P.O. Box 25123
Santa Fe, New Mexico 87504-5123
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
