Form 53-107 - Texas Securities Inventory Form

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COMPTROLLER OF PUBLIC ACCOUNTS
53-107
(Rev.2-08/2)
UNCLAIMED PROPERTY
PRINT FORM
CLEAR FIELDS
TEXAS SECURITIES INVENTORY FORM
Holder name
Federal employer identification number
Holder address
City
State
ZIP code
Contact person
Phone (Area code and number)
DIRECTIONS: For each stock certificate mailed to the Comptroller, please provide security issue name, including class and
type, and number of shares or certificate number (for example: ABC Inc. Common - 600 shares or XYZ Corp Class B Pre-
ferred - 150 shares). NOTE: The names of missing shareholders reported on Form 53-106, Report of Securities and Related
Cash, are not to be listed on this form.
MAIL SECURITIES INVENTORY FORM, REPORT OF SECURITIES AND RELATED CASH, REMITTANCE CHECK AND
PHYSICAL STOCK CERTIFICATES (if any) TO:
COMPTROLLER OF PUBLIC ACCOUNTS
Unclaimed Property Holder Reporting Section
P.O. Box 12019
Austin, TX 78711-2019
NUMBER OF
SECURITY ISSUE NAME
SHARES PER
CERTIFICATE
TOTAL NUMBER OF SHARES MAILED

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