Texas Unclaimed Property

Owner Claim Form

**-***

(Rev. 7-15/8)

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Under Ch. 559, Government Code, you are entitled to review, request and correct information we 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 phone number listed on this form. 24205757

Claim ID

CHARLES WILLIAMS

101 E 11TH ST

WESLACO, TX 78596-7023 COMPTROLLER OF PUBLIC ACCOUNTS Unclaimed Property Claims Section

P.O. Box 12046

Austin, TX 78711-2046

Mail to:

A. INSTRUCTIONS

Please complete, sign and return the claim form with a copy of your identification even if you are unable to provide all the requested documents.

Listed below are the documentation requirements to start this claim. Please attach all supporting documentation BEHIND the claim form. (Please keep copies of all documents submitted; we cannot send back original documentation.) Documentation verifying the Social Security number for the claimant. Examples include a copy of the Social Security card, earnings statement, or an IRS tax document. If there is no Social Security card, a form 1099 or paycheck stub with the Social Security number on it may be used.

Documentation from public records is not acceptable. Proof of SSN for Claimant

A copy of the current driver’s license for the claimant. If there is no driver’s license, send a current government issued identification card or passport. Proof of ID for claimant

A copy of any document verifying business dealings with the reporting company as it relates to the funds. Examples include a copy of the policy or proof of premium payments.

Property ID(s): 21336600

Insurance Policy/Premium

Payment

Legal description, well, county and survey name, and any other relevant information.

Property ID(s): 17189292, 17189362, 20948706, 20948831, 20948906, 20949024, 20949221, 20949502, 21295011, 47048539, 50901604, 58485328 Mineral Property Info

A copy of the division order showing royalty interest in claimed property. The claim amount may change to reflect additional current production payments. Property ID(s): 17189292, 17189362, 20948706, 20948831, 20948906, 20949024, 20949221, 20949502, 21295011, 47048539, 50901604, 58485328 Division Order

A copy of any document verifying business dealings with the reporting company as it relates to the funds. Examples include a copy of payment or deposit receipt.

Property ID(s): 21125036

Payment or Deposit

Receipt

A copy of any document verifying business dealings with the reporting company as it relates to the funds. Examples include a copy of a W-2 form or paycheck stub.

Property ID(s): 20581266

W2/Paycheck

A copy of any document verifying business dealings with the reporting company as it relates to the funds. Examples include a copy of an account statement or deposit slip.

Property ID(s): 19173939

Account

Statement/Deposit

A copy of any document verifying business dealings with the reporting company as it relates to the funds.

Property ID(s): 20284976, 21424611

Proof of Business with

Holder

The original check issued by the reporting company. Property ID(s): 20546263

Original Check - MS16

The original check and/or document verifying business dealings with the reporting company as it relates to the funds.

Property ID(s): 22220918

Original Check -

Verification

Texas Unclaimed Property

Owner Claim Form

53-120

(Rev. 7-15/8) Claim ID

24205757

B. CLAIMANT INFORMATION

Email address

City State ZIP code

Current mailing address

Name (Last) (First) (Middle) (Maiden) Social Security Number Additional Owner (Last) (First) (Middle) (Maiden) Social Security Number Daytime phone (Area code and number)

FAX (Area code and number)

C. AFFIDAVIT

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

Additional owner's signature Date

Would you like to contribute all or part of your claim to the Match the Promise Foundation?

Yes

No

X 1%

Texas Unclaimed Property

Owner Claim Form

53-120

(Rev. 7-15/8) Claim ID

24205757

D. PROPERTY INFORMATION

# Owner Property ID Company/Security Name Year Type of Property Value CHARLES WILLIAMS

1122 ELEANOR ST

1) AUSTIN, TX 787212116 19173939 CAPITAL ONE FINANCIAL CORP 2003 SAVINGS ACCOUNT $264.15 CHARLES WILLIAMS

21222 BRIDGEMEADOW

LANE

KATY, TX 774490000

2) 22220918 STATE OF LOUISIANA 2014 PENSION CHECK $269.79 CHARLES WILLIAMS

400 N INDUSTRIAL #

3) WACO, TX 767100000 21336600 ING LIFE INS & ANNUITY CO OTHER AMOUNTS DUE UNDER 2008 POLICY TERMS $468.50

CHARLES WILLIAMS

215 E ST CHARLES

4) CROSBY, TX 775320000 20948706 ENERGEN RESOURCES CORP 2009 MINERAL ROYALTY $42.90 CHARLES WILLIAMS

215 E ST CHARLES

5) CROSBY, TX 775320000 20949221 ENERGEN RESOURCES CORP 2013 MINERAL ROYALTY $6.38 CHARLES WILLIAMS

215 E ST CHARLES

6) CROSBY, TX 775320000 20949502 ENERGEN RESOURCES CORP 2014 MINERAL ROYALTY $10.62 CHARLES WILLIAMS

215 E ST CHARLES

7) CROSBY, TX 775320000 17189292 VENDERA RESOURCES TXLA LLC

CURRENT PRODUCTION

2015 PAYMENT $10.55

CHARLES WILLIAMS

215 E ST CHARLES

8) CROSBY, TX 775320000 17189362 VENDERA RESOURCES TXLA LLC

CURRENT PRODUCTION

2016 PAYMENT $5.33

CHARLES WILLIAMS

215 E ST CHARLES

9) CROSBY, TX 775320000 20948831 ENERGEN RESOURCES CORP CURRENT PRODUCTION 2010 PAYMENT $144.26

CHARLES WILLIAMS

215 E ST CHARLES

10) CROSBY, TX 775320000 20948906 ENERGEN RESOURCES CORP CURRENT PRODUCTION 2011 PAYMENT $15.17

CHARLES WILLIAMS

215 E ST CHARLES

11) CROSBY, TX 775320000 20949024 ENERGEN RESOURCES CORP CURRENT PRODUCTION 2012 PAYMENT $12.54

CHARLES WILLIAMS

12-000****** 21295011 ENERVEST OPERATING LLC CURRENT PRODUCTION 2009 PAYMENT $30.95

Texas Unclaimed Property

Owner Claim Form

53-120

(Rev. 7-15/8) Claim ID

24205757

Property Information continued

# Owner Property ID Company/Security Name Year Type of Property Value CHARLES WILLIAMS

215 E ST CHARLES

13) CROSBY, TX 775**-******** VENDERA RESOURCES TXLA LLC

CURRENT PRODUCTION

2017 PAYMENT $4.88

CHARLES WILLIAMS

215 E ST CHARLES

14) CROSBY, TX 775**-******** VENDERA RESOURCES TXLA LLC

CURRENT PRODUCTION

2018 PAYMENT $6.04

CHARLES WILLIAMS

215 E ST CHARLES

15) CROSBY, TX 775**-******** XTO ENERGY INC CURRENT PRODUCTION 2019 PAYMENT $0.03

CHARLES WILLIAMS

2706 22ND AVE N

TEXAS CITY, TX

775900000

16) 20581266 PILOT CORP 2010 WAGES, PAYROLL, OR SALARY $55.73 CHARLES WILLIAMS

2504 MCFARLAND ST

CADDO MILLS, TX

751350000

SALLY WILLIAMS

2504 MCFARLAND ST

CADDO MILLS, TX

751350000

17) 20284976 REPUBLIC BANCORP INC 2014 REFUND OR REBATE DUE $65.05 CHARLES WILLIAMS

3610 CARSON DR

AMARILLO, TX

791090000

18) 20546263 AMERICAN GEN LIFE &

ACCIDENT INS CO

ANY OTHER MISCELLANEOUS

2013 OUTSTANDING CKS $25.65

CHARLES WILLIAMS

4321 TAHOE DR

FORT WORTH, TX

761193859

19) 21424611 WAL MART STORES INC & SUBS ANY OTHER MISC INTANGIBLE 2009 PERSONAL PROP $40.00

CHARLES WILLIAMS

7808 CORONA CT

ARLINGTON, TX

760020000

20) 19579518 GENUINE PARTS CO / GENUINE

PARTS CO

UNDELIVERED STOCK

2007 RETURNED BY P.0. 1.0000 shares

CHARLES WILLIAMS

800 ROSS AVE APT

2143

DALLAS, TX 752021815

21) 21125036 AMBIT ENERGY HOLDINGS LLC 2016 UTILITY DEPOSIT $32.68 GRAND TOTAL of PROPERTY Cash: $1,511.20

FEDERAL PRIVACY ACT. Disclosure of your social security number is required and authorized under law for the purpose of tax administration and identification of any individual affected by applicable law. 42 U.S.C. Sec. 405(c)(2)(C)(i); Tex. Gov't Code Secs. 403.011, 403.015, 403.055 and 403.078. Release of information on this form in response to a public information request will be governed by the Public Information Act, Chapter 552, Government Code.

For more information regarding unclaimed property, the claim process and documentation requirements, or to check the current status of your claim, please visit our website at ClaimItTexas.gov. You can also call 1-800-***-****. The Austin number is 512-***-****. State law limits the fees charged by all outside search firms or private investigators who assist you in locating unclaimed property to no more than 10% of the value of the property.

Make a Difference. Donate to Match the Promise! Now that you have located unclaimed property that may belong to you, you can choose to donate a portion of it to the "Match the Promise Foundation", a new fund that provides matching scholarships to families in the state's prepaid college tuition plan. To donate, check "Yes" on your claim form when asked whether you want to Contribute to Match the Promise. Enter the percent you wish to donate. For details on the Match the Promise Foundation, go to MatchThePromise.org.

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