53-120

(Rev.4-15/7)

PRINT YOUR CLAIM

Texas Unclaimed Property

Original Owner Claim Form

Claim number

16029318

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.

*16029318*

David Bump
32 WILDWOOD DR
CABOT, AR 72023-9327

Name (Last)

Mail to: COMPTROLLER OF PUBLIC ACCOUNTS

Unclaimed Property Claims Section
P.O. Box 12046
Austin, TX 78711-2046

CLAIMANT INFORMATION

(First)

Bump

(Middle)

David

Additional owner (Last)

(Maiden)

Social Security number

(Maiden)

Social Security number

Christian

(First)

XXXXXXXXX

(Middle)

Current mailing address

Daytime phone (Area code and number)

32 WILDWOOD DR

(501)286-0141

City

State

ZIP code

CABOT

AR

Email address

72023
FAX (Area code and number)

saint.bump@gmail.com

()-

The named Claimant hereby certifies that this claim for property presumed abandoned is valid and just, that all statements herein are true and correct,
and that upon payment of this claim said Claimant will indemnify and hold harmless the State of Texas, the Comptroller and its employees from any
damages, claims, or losses of any kind resulting from the payment of the property to the Claimant.
Claimant's signature

Date
Would you like to contribute all or part of your
claim to the Match the Promise Foundation?

Additional owner's signature

YES NO

Date

PLEASE COMPLETE, SIGN, AND RETURN THE CLAIM FORM WITH A COPY OF YOUR IDENTIFICATION
EVEN IF YOU ARE UNABLE TO PROVIDE ALL THE REQUESTED DOCUMENTS.

1
Reported property owner

PROPERTY INFORMATION --- FOR OFFICE USE ONLY

Reported additional owner

DAVID C BUMP
Reported property address

324 GRACE AVENUE #B FORT WORTH, TX 76116

Description

Property type

Wages, Payroll or Salary

Reporting company

Last active date

WHATABURGER REST LLC

Reported property owner

Claimed amount

1995

85.95

PROPERTY INFORMATION --- FOR OFFICE USE ONLY

Reported additional owner

Reported property address

Property type

Description

Reporting company

Last active date

--- FOR INTERNAL USE ONLY ---

Issued to

Claimed amount

Claim number

16029318
Approved by

Date

Number of properties

Total amount of claim

85.95

If you have any questions regarding Unclaimed Property, call 1-800-321-2274. The Austin number is 512-463-3040.

Instructions for Claim Number: 16029318

ORIGINAL OWNER CLAIM

The claimant must be 18 or older to file.

State law authorizes a handling fee for certain claims. There will be no fee if your
claim is not paid or if your claim is less than $100. The amount of the fee is 1.5%
for all claims valued at $100 or more. If a fee is assessed, it will be deducted from
the claim amount at the time of payment.

Please provide the following:

Please keep copies of all documents submitted; we cannot send back original
documentation.

1.Copy of claimant's photo identification (e.g. driver's license, state identification

card, passport, etc.)
2.Proof of Social Security Number (SSN) for the Reported Property Owner and Reported
Additional Owner (see the Property Information box on your claim), for each property
on your claim
3.Documentation from your own files proving that the Reported Property Owner lived at
the Reported Property Address (see the Property Information box), for each property
on your claim
4.Documentation required for proving right to claim this owner's property:
Other documentation requested for each property below:
- Property # 1
No additional documents requested.