Texas Report Of Securities And Related Cash Form
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1Page _____ of _____
53-106
COMPTROLLER OF PUBLIC ACCOUNTS
(Rev.7-09/2)
UNCLAIMED PROPERTY HOLDER REPORTING SECTION
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
To
$
Owner driver's license number
Owner e-mail address
COMPLETE ADDITIONAL OWNER LINE (BELOW) IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY.
Additional owner last name
First name / middle initial
Additional owner title
Additional owner Social Security Number
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
To
$
Owner driver's license number
Owner e-mail address
COMPLETE ADDITIONAL OWNER LINE (BELOW) IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY.
Additional owner last name
First name / middle initial
Additional owner title
Additional owner Social Security Number
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
To
$
Owner driver's license number
Owner e-mail address
COMPLETE ADDITIONAL OWNER LINE (BELOW) IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY.
Additional owner last name
First name / middle initial
Additional owner title
Additional owner Social Security Number
Shares
Cash
PAGE
*
NOTE: THIS REPORT MUST BE ACCOMPANIED BY
$
TOTALS
SECURITIES INVENTORY, FORM 53-107.
Shares
Cash
IF LAST PAGE, ENTER GRAND TOTAL REMITTED
$
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