UNCLAIMED PROPERTY HOLDERS
                       PAYOR INFORMATION FORM
53-316
(Rev.6-07/4)
                                 New
                                 Change              effective with next payment due  ____ /____ / ____

            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 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.