Free 53-115 Unclaimed Property Holder Reimbursement Request - Texas

CLEAR FORM
53-115 (Rev.9-07/2)

PRINT FORM

TEXAS UNCLAIMED PROPERTY

HOLDER REIMBURSEMENT REQUEST FORM
(For Property Returned to Owner) COMPTROLLER OF PUBLIC ACCOUNTS Unclaimed Property Division Claims Section P.O. Box 12019 Austin, TX 78711-2019

HOLDER INFORMATION
Holder name Tax ID number

Mailing address

City

State

ZIP code

E-mail address

FAX number (Area code and number)

(
Department

)
Extension

Phone (Area code and number)

( PROPERTY INFORMATION
Report year Report amount Property type code Aggregate

)

Property amount

Claim amount

Number of Shares

YES
Owner name as indicated on report

NO
Additional owner as indicated on report

Owner address

Property description

Please provide proof of payment for each owner included on the Reimbursement Form and supplemental pages. Please attach a copy of the cleared check showing the owner's endorsement or proof of the account being reactivated.

INDEMNIFICATION AND AFFIDAVIT OF OFFICER
Upon payment by the Texas Comptroller of Public Accounts of the reimbursement described above, (Co. Name) ___________________________________ agrees to indemnify and hold harmless the Comptroller, its employees and agents from all losses, suits, actions or claims arising from or related to any other party who hereafter asserts or attempts to establish a right to payment of the above described funds. COMPTROLLER INDEMNIFICATION IS EFFECTIVE WHEN SIGNED.

Signature ___________________________________________________ Title _______________________ Date _____________________________ If you have any questions regarding Unclaimed Property, you may call (800) 321-2274. The Austin number is (512) 463-3040. Our FAX number is (512) 936-6224; toll-free FAX number is (888) 908-9991.
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 toll-free number listed on this form.