Scribd
Upload
390 views1 page

Holder Refund and Reimbursement Request Form: Indemnification and Affidavit of Officer

This document is a form for holders of unclaimed property to request a refund or reimbursement from the Texas Unclaimed Property Division. It requests information about the holder, the unclaimed property, and requires the holder to indemnify the state comptroller if payment is made. The holder must provide their name, tax ID, address, contact details, the report year and amount of the unclaimed property, and the reason for the request, such as paying the owner directly or a report error.

Uploaded by

Phyliss Robinson
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
390 views1 page

Holder Refund and Reimbursement Request Form: Indemnification and Affidavit of Officer

This document is a form for holders of unclaimed property to request a refund or reimbursement from the Texas Unclaimed Property Division. It requests information about the holder, the unclaimed property, and requires the holder to indemnify the state comptroller if payment is made. The holder must provide their name, tax ID, address, contact details, the report year and amount of the unclaimed property, and the reason for the request, such as paying the owner directly or a report error.

Uploaded by

Phyliss Robinson
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

53-116

(Rev.3-16/5) CLEAR FORM PRINT FORM

Texas Unclaimed Property Division


Holder Refund and Reimbursement Request Form

Comptroller of Public Accounts


Unclaimed Property Division, Research and Correspondence Section
P.O. Box 12046
Austin, TX 78711-2046

Holder Information:
Holder name Tax ID number

Mailing address

City State ZIP code

Email address FAX number (Area code and number)

( )
Department Phone (Area code and number) Extension

Property Information: Property #1 * for additional properties, use Form 53-117 (cash) or 53-130 (shares)
Report year Report amount Property type code Aggregate Property amount

Yes No
Owner name as indicated on report

Owner address Reason for request

Paid owner directly


(Proof of payment attached)
Property description
Reported in error
(Explanation attached)

Indemnification and Affidavit of Officer


Upon payment by the Texas Comptroller of Public Accounts of the reimbursement/refund requested here,

________________________________________________ agrees to indemnify and hold harmless the Comptroller,


COMPANY NAME

its employees and agents from all losses, suits, actions or claims arising from or related to any other party who

hereafter asserts or attempts to establish a right to payment of the requested funds.

Date

Print name Title

If you have any questions regarding this form, call 1-800-321-2274 or 512-463-3040.
Our FAX number is 1-888-908-9991 or 512-936-6224.

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 phone number listed on this form.

You might also like