Form 53-115 - Holder Reimbursement Request Form

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53-115
(Rev.10-09/3)
TEXAS UNCLAIMED PROPERTY
HOLDER REIMBURSEMENT REQUEST FORM
(For Property Returned to Owner)
COMPTROLLER OF PUBLIC ACCOUNTS
Unclaimed Property Division
Claims Section
P.O. Box 12046
Austin, TX 78711-2046
HOLDER INFORMATION
Holder name
Tax ID number
Mailing address
City
State
ZIP code
E-mail address
FAX number (Area code and number)
(
)
Department
Phone (Area code and number)
Extension
(
)
PROPERTY INFORMATION
Report year
Report amount
Property type code
Aggregate
Property amount
Claim amount
Number of Shares
YES
NO
Owner name as indicated on report
Additional owner as indicated on report
Owner address
Property description
Please provide proof of payment for each owner included on the Reimbursement Form and supplemental pages. Please attach a copy of the
cleared check showing the owner’s endorsement or proof of the account being reactivated.
INDEMNIFICATION AND AFFIDAVIT OF OFFICER
Upon payment by the Texas Comptroller of Public Accounts of the reimbursement described above,
____________________________________
(Co. Name)
agrees to indemnify and hold harmless the Comptroller, 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 above described funds.
COMPTROLLER INDEMNIFICATION IS EFFECTIVE WHEN SIGNED.
Signature ___________________________________________________ Title ________________________ Date ______________________________
If you have any questions regarding Unclaimed Property, you can call (800) 321-2274 or (512) 463-3040.
Our FAX number is (512) 936-6224 or (888) 908-9991.
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, Gov-
ernment Code. To request information for review or to request error correction, contact us at the address or phone number listed on this form.

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