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                          53-120
                          (Rev.4-7/04)

TEXAS UNCLAIMED PROPERTY
                                                                                                                                                                                 Claim number
ORIGINAL OWNER CLAIM FORM
Under Ch. 559, Government Code, you are entitled to review, request, and correct information we                                                                                                 05140741
have on file about you, with limited exceptions in accordance with Ch. 552, Government Code.
To request information for review or to request error correction, contact us at the address or tOil-free
number listed on this form.

             EARL KINARD                                                                                                                                  Mail To: COMPTROLLER OF PUBLIC ACCOUNTS
             6810 S 1ST ST #101                                                                                                                                    Unclaimed Property Claims Section
             AUSTIN, TX 78745·                                                                                                                                     P.O. Box 12019
                                                                                                                                                                   Austin, TX 78711-2019

                                         PLEASE SEE THE INSTRUCTIONS                                                 BEFORE COMPLETING                                              THIS FORM
     '" i3"""~-                          311".     ':J'"   e . 1;;. CLAIMAN'T                                      INFORMA nON                            iIi.,                -" "''0,.                 Jii~ -,~,                                 "" Ii!l'",~,
                                                                                                                                            ."'" ~                                                                              '"
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                                                                                                   I   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 any
damages, claims, or losses of any kind resulting from the payment of the property to the Claimant.
                    Claimant's      signature                                                                                                                                   Date
sign ~
here
                    Additional owner's signature                                                                                                                                Date
sign ~
here
                                                                PLEASE                     DO NOT WRITE BELOW THIS LINE

  1      ~'_'li'.                        -~~.       ,"            '"it,,_                         -"-••":::PROPERTY-IN~RMATIONP>-            ~~-            ~;~                "",~'ll~~       £)'~      . ''''.:         ,~.         ~ 'I!,f"          ~*';-
                                                                                                                                                                                                                                                          _
Reported property owner                                                                                              Reported additional owner
     EARL KINARD
Reported property address

     2104 CHICON AUSTIN, TX 78702
Property type                                                          ~                                             Description

     GROUP POLICY CLAIM PMT OR BENEFIT                                                                                     06038375000003228784                                    0049226437
                                                                                                                                                                                           I
                                                                                                                      i,

Reporting company                                                                                                    Last active date                                                       Claimed amount
'-"--HARTFORD FIRE INS CO                                                                                                             12/11/1997                                                                     $233.40
                       ,
~'i         -
  2 ~~';;L~.~"'"                    "'~'"                . ,,,"~,i\l
                                                                                            if<     "~PRQPER:rY    If'j~RMATION              ':-'*'                rlf'       ,,;;;..~.~        .                  ,
                                                                                                                                                                                                       "A"',;.,., ..                 .:   ~'   -        ,!i r/tit.-
Reported property owner                                                                                              Reported additional owner

     EARL KINARD
Reported property address

     2104 CHICON                   AUSTIN, TX 78702
Property type                                                                                                        Description

     GROUP POLICY CLAIM PMT OR BENEFIT                                                                                     06038375000003228784                                    0049226439
Reporting company                                                                                                    Last active date

                                                                                                                                      12/11/1997
                                                                                                                                                                                           IClaimed amount
                                                                                                                                                                                                                     $233.40
     HARTFORD FIRE INS CO
                ,
  ,.~i}·~;6,,_~-~ ~~~r
                er;                                         ~      I!!>i'. ~       i'"    '" ~      i:. FOR INTERNAL'r(JSl!   ONLY --r-;Jt:,.         "      ';i              r =-;""''1         ,
                                                                                                                                                                                                 'I'
                                                                                                                                                                                                                    it ~.
                                                                                                                                                                                                                    t', -"~                        .,   ~~\t;p        -
Issued to



Approved       by                                                              I
                                                                               Date
                                                                                                                     Number of properties

                                                                                                                                        2
                                                                                                                                                                          I
                                                                                                                                                                          Total amount of claim
                                                                                                                                                                                                         $466.80
        If you have any questions regarding Unclaimed                                    Property, you may call 1-800-321-2274.             The Austin number                       IS     512/463-3040.              If you are calling
                          from a Telecommunications                    Device for the Deaf (TOO), the toll-free number is 1-800-248-4099. or in Austin, 512/463-4621,

				
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