Form 497-Up-Mir - Report Of Unclaimed Property

Page __________

Of ____________

OKLAHOMA STATE TREASURER

HOLDER

State of Oklahoma

Unclaimed Property Division

2300 N. Lincoln Blvd., Rm. 217

(City)

(State)

(Zip)

Oklahoma City, Okahoma 73105-4895

FEDERAL EMPLOYER ID NO.

REPORT YEAR

REPORT OF UNCLAIMED PROPERTY

Note: According to chapter 80 735:80-3-5 "Regardless of the amount of the mineral interest proceeds, if the proceeds are presumed unclaimed under the Uniform Unclaimed Property Act, or under the Unclaimed Property Laws of any other 

State, the mineral interest that generated such proceeds is also presumed abandoned and shall become reportable to OST. It is also required that the names of last-known owners of mineral interest, their percentages of ownership and the

 legal description of the mineral interest be reported to OST."

PROPERTY

NAUPA

AMOUNT

ADDITIONS

DEDUCTIONS AND

AMOUNT

LEGAL

WELL

OWNER

DATE OF LAST

OWNER'S LAST NAME, FIRST NAME, MIDDLE NAME

OWNER'S SOCIAL

DESCRIPTION PROPERTY

REPORTED

TO AMOUNT

WITHHOLDINGS

REMITTED

DESCRIPTION

NAME

PERCENTAGE

TRANSACTION OR

LAST KNOWN STREET NAME

SECURITY NUMBER

OWNER

CODE

AS DUE OWNER

REPORTED TYPE

* AMOUNT

COUNTY NAME & STATE

DATE PROPERTY

CITY, STATE, ZIP

OR FEI NUMBER

NUMBER

*(See note below)

SECTION, TOWNSHIP, RANGE

BECAME PAYABLE

(1)

(2)

(3)

(4)

(5a)

(5b)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

0.00000000%

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

497-UP-MIR

(IF THIS IS LAST PAGE OF REPORT, ENTER GRAND TOTAL)

Revision 10/04/2016

*Must be entered as a negative number in column 5b.