Texas Unclaimed Property Payment Form
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1*5311900W041505*
53-119
PRINT FORM
RESET FORM
(Rev.4-15/5)
AGENCY USE ONLY
Texas Unclaimed Property Payment
Ho
lder federal employer identification number
D
iv
Year
Seq
Type
(F
EIN)
Holder name and address
State of incorporation or charter
Date of incorporation or charter
Phone number
Phone number
Report Contact
Claims Contact
Name
Name
Mailing address
Mailing address
Email address
Email address
FAX number
FAX number
Holder's primary business activity:
SIC code:
NUMBER
Circle all report media used and provide report totals.
SHARES
CASH
OF ITEMS
Confirmation number must be included if filing via Internet
$
Diskette / CD
(CD or Diskette submission requires prior approval from CPA staff.)
$
(Transmission confirmation n
umber
E
)
Internet
PAYMENT AMOUNT
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
Comptroller of Public Accounts
For assistance, call
Unclaimed Property, Holder Reporting Section
1-800-321-2274, option 5.
Title
P.O. Box 12019
Austin, TX 78711-2019
* * * DO NOT DETACH * * *
53-119
(Rev.4-15/5)
Payment for Unclaimed Property
Complete one copy for each check submitted.
9 0 1 0 0
1. T code
1.
PAYMENT
5 5 2
2. Deposit code
2.
1
3. Federal Employer Identification Number (FEIN)
3.
4. Amount of check (Dollars and cents)
4.
AGENCY USE ONLY
Holder name
PM
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