ASSIGNMENT OF RIGHT TO REFUND

To the Comptroller of Public Accounts for the State of Texas (hereinafter “Comptroller”):

(1) My name is ______________________________________ , and I am a duly authorized representative of
__________________________________________ (the “Assignor”). By executing this Assignment of Right
to a Refund (“Assignment”), the Assignor assigns all rights and interest to the tax refund herein described that
the Assignor may have to ______________________________ (the “Assignee”), subject to the limitation noted
herein. The Assignee’s Taxpayer Number is ____________________ (if permitted in Texas).

(2) Assignor hereby assigns the Assignee (check whichever is applicable):
_____ a. The right to file a request for a refund and to receive the refund.
_____ b. The right to receive the refund only.

(3) The tax refund that is the subject of this Assignment is described as follows:
Tax Type: ________________________________________
Period: __________________________________________
Transactions: __________________________________________________________________________
________________________________________________________________                                                                (Attach schedule, if necessary.)
Other specific limitations: _________________________________________________________________

(4) The Assignor understands that the Comptroller may require both parties to provide documents or information
necessary for the Comptroller to verify the validity of the refund claim and/or to transfer any verified amount to
the Assignee.

(5) By executing this Assignment, the Assignor affirms that the Assignor has neither previously claimed a refund
nor taken a credit on a return for taxes that are subject of this Assignment, and further affirms that the Assignor
will not claim a refund or a credit for those taxes in the future.

Executed _______ day of _________________ , 20 ____ .

                        ______________________________________                                                                  _______________
                        Assignor Entity Name                                                                                    Assignor Taxpayer Number

                        _______________________________________________________
                        Print or type the name of person authorizing assignment

                        _______________________________________________________
                        Relationship to entity (i.e., President, Treasurer)

                        ______________________________________                                                                  _______________
                        Signature of person authorizing assignment                                                              Date

                        _______________________________________________________
                        Area code/daytime phone number

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 Texas Comptroller’s office
Form 00-985 (Rev.9-05/2)