53-105 (Rev. 6-97/2)
COMPTROLLER OF PUBLIC ACCOUNTS UNCLAIMED PROPERTY HOLDER REPORTING SECTION PAGE _____ OF _____
Federal Employer Identification Number (FEIN)
TEXAS REPORT OF UNCLAIMED PROPERTY
Holder name
Item no.
Property type
Property description
Owner last name
First name/middle initial
Title
Mailing address
City, state, ZIP code
Country, if not U.S.A. Amount remitted to Comptroller
Date of last contact
OR
FROM
Periodic payments TO
Owner Social Security Number (SSN)
$
Additional owner title Additional owner SSN
COMPLETE ADDITIONAL OWNER BOXES (BELOW) IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY.
Additional owner last name First name/middle initial
Additional owner last name
First name/middle initial
Additional owner title
Additional owner SSN
Item no.
Property type
Property description
Owner last name
First name/middle initial
Title
Mailing address
City, state, ZIP code
Country, if not U.S.A. Amount remitted to Comptroller
Date of last contact
OR
FROM
Periodic payments TO
Owner Social Security Number (SSN)
$
Additional owner title Additional owner SSN
COMPLETE ADDITIONAL OWNER BOXES (BELOW) IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY.
Additional owner last name First name/middle initial
Additional owner last name
First name/middle initial
Additional owner title
Additional owner SSN
Item no.
Property type
Property description
Owner last name
First name/middle initial
Title
Mailing address
City, state, ZIP code
Country, if not U.S.A. Amount remitted to Comptroller
Date of last contact
OR
FROM
Periodic payments TO
Owner Social Security Number (SSN)
$
Additional owner title Additional owner SSN
COMPLETE ADDITIONAL OWNER BOXES (BELOW) IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY.
Additional owner last name First name/middle initial
Additional owner last name
First name/middle initial
Additional owner title
Additional owner SSN
Item no.
Property type
Property description
Owner last name
First name/middle initial
Title
Mailing address
City, state, ZIP code
Country, if not U.S.A. Amount remitted to Comptroller
Date of last contact
OR
FROM
Periodic payments TO
Owner Social Security Number (SSN)
$
Additional owner title Additional owner SSN
COMPLETE ADDITIONAL OWNER BOXES (BELOW) IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY.
Additional owner last name First name/middle initial
Additional owner last name
First name/middle initial
Additional owner title
Additional owner SSN
IF LAST PAGE, ENTER GRAND TOTAL REMITTED
$
PAGE TOTAL
$