Free 53-316.pmd - Texas

UNCLAIMED PROPERTY HOLDERS PAYOR INFORMATION FORM
53-316 (Rev.6-07/4)

New Change HOLDER NAME: ADDRESS:

effective with next payment due ____ /____ / ____

_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

FEDERAL ID #:

__________________________________________________

CATEGORY OF PAYMENT: UNCLAIMED PROPERTY

CONTACT: TITLE:

_____________________________________________________________________ _____________________________________________________________________

PHONE #: ( ________ ) ___________________ ext. ___________ FAX: ___________________

ELECTRONIC FUNDS TRANSFER INFORMATION (Please indicate your preference by checking one of the boxes below):

ACH Credit with Addenda ACH Debit
If checked, please provide additional information below:

BANK NAME: ______________________________________________________________ CITY/STATE: ______________________________________________________________ TRANSIT/ROUTING NUMBER: ______________________________________________________________________ BANK ACCOUNT NUMBER: ______________________________________________________________________ I hereby authorize the Texas Comptroller of Public Accounts to initiate ACH Debit entries to the financial institution account indicated above for payments owed to the state of Texas. Amounts shall correspond to payment information entered into the TEXNET System for the applicable period. This authorization is to remain in full force and effect until the Comptroller receives written notification from me of termination and has a reasonable opportunity to act on it. Name: ________________________________________________________________________________ Signature: _______________________________________________________________________ Date: ____________________________

PLEASE COMPLETE AND RETURN THIS FORM TO: COMPTROLLER OF PUBLIC ACCOUNTS CASH MANAGEMENT PROGRAMS P.O.BOX 12608 AUSTIN, TX 78711 PHONE: (800) 531-5441, EXTENSION 33010 OR FAX: (512) 463-1364 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.