53-120 (Rev.11-09/6)

Texas Unclaimed PropertyOriginal Owner Claim Form Claim number

Under Ch. 559, Government Code, you are entitled to review, request and correct information we have on fileabout you, with limited exceptions in accordance with Ch. 552, Government Code. To request information forreview or to request error correction, contact us at the address or phone number listed on this form.

Mail to: COMPTROLLER OF PUBLIC ACCOUNTS Unclaimed Property Claims SectionP.O. Box 12046 Austin, TX 78711-2046

PLEASE SEE THE INSTRUCTIONS BEFORE COMPLETING THIS FORM

CLAIMANT INFORMATION Name (Last) (First) (Middle) (Maiden) Social Security number

Additional owner (Last) (First) (Middle) (Maiden) Social Security number

Current mailing address Daytime phone (Area code and number)

City State ZIP code

E-mail address FAX (Area code and number)

The named Claimant hereby certifies that this claim for property presumed abandoned is valid and just, that all statements herein are true and correct,and that upon payment of this claim said Claimant will indemnify and hold harmless the State of Texas, the Comptroller and its employees from anydamages, claims, or losses of any kind resulting from the payment of the property to the Claimant.

Claimant's signature Date Would you like to contribute all or part of yourclaim to the Match the Promise Foundation?

Additional owner's signature Date YES NO %

PLEASE COMPLETE, SIGN, AND RETURN THE CLAIM FORM WITH A COPY OF YOUR IDENTIFICATIONEVEN IF YOU ARE UNABLE TO PROVIDE ALL THE REQUESTED DOCUMENTS.

PROPERTY INFORMATION --- FOR OFFICE USE ONLY Reported property owner Reported additional owner

Reported property address

Property type Description

Reporting company Last active date Claimed amount

PROPERTY INFORMATION --- FOR OFFICE USE ONLY Reported property owner Reported additional owner

Reported property address

Property type Description

Reporting company Last active date Claimed amount

--- FOR INTERNAL USE ONLY ---Issued to Claim number

Approved by Date Number of properties Total amount of claim

If you have any questions regarding Unclaimed Property, call (800) 321-2274. The Austin number is (512) 463-3040.

Instructions for Claim Number: 11351980

ORIGINAL OWNER CLAIMThe claimant must be 18 or older to file.

Please provide the following:

1.Copy of claimant's photo identification (e.g. driver's license, state identification

card, passport, etc.)

2.Proof of Social Security Number (SSN) for the Reported Property Owner and Reported

Additional Owner (see the Property Information box on your claim), for each property

on your claim

3.Documentation from your own files proving that the Reported Property Owner lived at

the Reported Property Address (see the Property Information box), for each property

on your claim

Other documentation requested for each property below:

- Property # 1

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