53-106 (1-97)
COMPTROLLER OF PUBLIC ACCOUNTS UNCLAIMED PROPERTY HOLDER REPORTING SECTION
Page _____ of _____
TEXAS REPORT OF SECURITIES AND RELATED CASH
Holder name Federal employer identification number (FEIN)
Item no.
Stock property type
Cash property type
Remitted security name
Cusip number
Name of unexchanged shares (SC10) or liq. unredeemed shares (SC13)
No. of SC10 or SC13 shares
Owner last name
First name / middle initial
Title
Mailing address
City, state and ZIP code
Country, if not USA
Date of last contact
OR
Periodic payments
Owner Social Security Number
Remitted shares see note below *
Remitted cash
From
Additional owner last name
To
First name / middle initial Additional owner title
$
Additional owner Social Security Number
COMPLETE ADDITIONAL OWNER LINE (BELOW) IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY.
Item no.
Stock property type
Cash property type
Remitted security name
Cusip number
Name of unexchanged shares (SC10) or liq. unredeemed shares (SC13)
No. of SC10 or SC13 shares
Owner last name
First name / middle initial
Title
Mailing address
City, state and ZIP code
Country, if not USA
Date of last contact
OR
Periodic payments
Owner Social Security Number
Remitted shares see note below *
Remitted cash
From
Additional owner last name
To
First name / middle initial Additional owner title
$
Additional owner Social Security Number
COMPLETE ADDITIONAL OWNER LINE (BELOW) IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY.
Item no.
Stock property type
Cash property type
Remitted security name
Cusip number
Name of unexchanged shares (SC10) or liq. unredeemed shares (SC13)
No. of SC10 or SC13 shares
Owner last name
First name / middle initial
Title
Mailing address
City, state and ZIP code
Country, if not USA
Date of last contact
OR
Periodic payments
Owner Social Security Number
Remitted shares see note below *
Remitted cash
From
Additional owner last name
To
First name / middle initial Additional owner title
$
Additional owner Social Security Number
COMPLETE ADDITIONAL OWNER LINE (BELOW) IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY.
*NOTE: THIS REPORT MUST BE ACCOMPANIED BY
SECURITIES INVENTORY, FORM 53-107.
PAGE TOTALS
Shares
Cash
$
Shares Cash
IF LAST PAGE, ENTER GRAND TOTAL REMITTED
$