Free 53-119 Unclaimed Property Holder Report and Payment - Texas

53-119 (Rev.2-08/2)

TEXAS UNCLAIMED PROPERTY HOLDER REPORT AND PAYMENT
Holder name and address

Holder federal employer identification number (FEIN)

Div

AGENCY USE ONLY Year Seq

Type

State of incorporation or charter Date of incorporation or charter

REPORT DUE DATE
Phone number

Phone number

REPORT CONTACT
Name Mailing address

CLAIMS CONTACT
Name Mailing address

E-mail address FAX number

E-mail address FAX number
PLEASE MARK ANY CHANGES TO THE ABOVE INFORMATION

Holder's primary business activity: Circle all report media used and provide report totals. Confirmation number must be included if filing via Internet Forms 53-105 / 53-119 Diskette (Number of diskettes) Magnetic tape/cartridge Internet (Transmission confirmation number E
)

SIC code: NUMBER OF ITEMS SHARES $ $ $ $
PAYMENT AMOUNT

CASH

The foregoing report contains a full and complete list of all property held by the undersigned that from the records of the undersigned, is abandoned under the laws of the State of Texas. The property delivered is a complete and correct remittance of all accounts; the existence and location of the listed owners are unknown; and the listed owners have not asserted an act of ownership with respect to the reported property. MAIL THIS FORM WITH YOUR PAYMENT TO: TEXAS STATE COMPTROLLER Unclaimed Property Division Holder Reporting Section P.O. Box 12019 Austin, TX 78711-2019 For assistance, call (800) 321-2274, ext. 6-6246, or in Austin, call (512) 936-6246.

$

Title

53-119 (Rev.2-08/2)

* * * DO NOT DETACH * * *

PAYMENT FOR UNCLAIMED PROPERTY
Complete one copy for each check submitted. 1. T code 3. Deposit code 4. Federal Employer's Identification Number (FEIN) 5. Amount of check (Dollars and cents)
Holder name

1. 3. 4. 5.

9 0 1 0 0 5 5 2 1

PAYMENT

AGENCY USE ONLY

PM