Free 53-116 Unclaimed Property Holder Refund Request - Texas

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53-116 (Rev.9-07/2)

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TEXAS UNCLAIMED PROPERTY

HOLDER REFUND REQUEST FORM
(For Property Reported in Error) 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)

(
Reason property was reported in error

)

PROPERTY INFORMATION
Report year Report amount Property type code Aggregate Property amount Number of shares

YES
Owner name as indicated on report

NO

Owner address

Property description

Based upon my personal knowledge, the information provided and set forth above on this form is true and correct.
Holder signature Date

Print name

Title

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.