Comptroller of Public Accounts Form 53-117 (Rev. 7-01/1)
TEXAS UNCLAIMED PROPERTY
HOLDER CLAIM FORM SUPPLEMENT
(to be used with the Holder Refund Request Form or the Holder Reimbursement Request Form) HOLDER INFORMATION
Holder Name: Tax ID Number:
PROPERTY INFORMATION
Report Year: Report Amount: Property Type: Aggregate: Yes No Property Amount: Claim Amount: No. of Shares:
Owner Name as Indicated on Report:
Owner Address:
Property Description:
PROPERTY INFORMATION
Report Year: Report Amount: Property Type: Aggregate: Yes No Property Amount: Claim Amount: No. of Shares:
Owner Name as Indicated on Report:
Owner Address:
Property Description:
PROPERTY INFORMATION
Report Year: Report Amount: Property Type: Aggregate: Yes No Property Amount: Claim Amount: No. of Shares:
Owner Name as Indicated on Report:
Owner Address:
Property Description:
PROPERTY INFORMATION
Report Year: Report Amount: Property Type: Aggregate: Yes No Property Amount: Claim Amount: No. of Shares:
Owner Name as Indicated on Report:
Owner Address:
Property Description: