Enlarge image | PRINT FORM CLEAR FORM UNCLAIMED PROPERTY HOLDERS PAYOR INFORMATION FORM 53-316 (Rev.3-17/5) New Change Effective date of change(s) ____ /____ / ____ HOLDER NAME: _______________________________________________________________________ ADDRESS: _______________________________________________________________________ _______________________________________________________________________ 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 Sys- tem 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: ____________________________ For assistance in completing this form, contact the TEXNET Hotline at (800) 531-5441, ext. 3-3010. PLEASE COMPLETE AND RETURN THIS FORM TO: EMAIL: Treasury.CSM.Cash.Mgmt.Programs.Section@cpa.texas.gov or COMPTROLLER OF PUBLIC ACCOUNTS Cash & Securities Management Division Cash Management Programs P.O. Box 12608 Austin, TX 78711-2608 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. |