Free 53-116 - Texas

53-118 (8-02)

PAYMENT FOR UNCLAIMED PROPERTY
Complete one copy for each check submitted.

Detach and mail the form below along with your payment(s) to:

TEXAS STATE COMPTROLLER OF PUBLIC ACCOUNTS Unclaimed Property Division P.O. Box 12019 Austin, TX 78711-2019

For assistance, call 1-800-321-2274, extension 6-6246, toll free nationwide, or in Austin, call (512)936-6246.

DETACH AND SEND ONLY THE COPY BELOW TO THE COMPTROLLER'S OFFICE
53-118 (8-02)

2.

PAYMENT FOR UNCLAIMED PROPERTY
Complete one copy for each check submitted.
1. T code ....................................................................... 1.

Shaded areas for Comptroller use only.

9 0 1 0 0 5 5 1

PAYMENT

3. Deposit code ............................................................. 3.

UNCLAIMED PROPERTY DEPOSIT CODES 551 - Accruing stock dividends 553 - Ongoing mineral production 552 - Annual holder report 556 - Interest and penalty

4. Federal Employer's Identification Number (FEIN) ..... 4.

5. Amount of check (Dollars and cents) ........................ 5.
Holder name Postmark date