53-105
COMPTROLLER OF PUBLIC ACCOUNTS
(Rev.7-09/3)
UNCLAIMED PROPERTY HOLDER REPORTING SECTION
TEXAS REPORT OF UNCLAIMED PROPERTY
PAGE ______ OF ______
Holder name
Federal Employer Identification Number (FEIN)
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.
OR
Date of last contact
Periodic payments
Owner Social Security Number (SSN)
Amount remitted to Comptroller
$
FROM
TO
Owner driver’s license number
Owner e-mail address
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 title
Additional owner SSN
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.
OR
Date of last contact
Periodic payments
Owner Social Security Number (SSN)
Amount remitted to Comptroller
$
FROM
TO
Owner driver’s license number
Owner e-mail address
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 title
Additional owner SSN
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.
OR
Date of last contact
Periodic payments
Owner Social Security Number (SSN)
Amount remitted to Comptroller
$
FROM
TO
Owner driver’s license number
Owner e-mail address
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 title
Additional owner SSN
Additional owner last name
First name/middle initial
Additional owner title
Additional owner SSN
IF LAST PAGE, ENTER
$
$
PAGE TOTAL
GRAND TOTAL REMITTED