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.