Payor Information Form
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1HEALTH AND HUMAN SERVICES COMMISSION
PAYOR INFORMATION FORM
89-103
(Rev.3-07/2)
New
Change
effective with next payment due ____ /____ / ____
PAYOR NAME: _____________________________________________________________________
ADDRESS: _____________________________________________________________________
_____________________________________________________________________
FEDERAL ID # / VENDOR ID #: __________________________________________________
CATEGORY OF PAYMENT: INTERGOVERNMENTAL TRANSFERS
CONTACT: _____________________________________________________________________
TITLE: _____________________________________________________________________
PHONE #: ( ________ ) ___________________ ext. ___________ FAX: ___________________
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:
FAX: (512) 463-1364
COMPTROLLER OF PUBLIC ACCOUNTS
CASH MANAGEMENT PROGRAMS
P.O.BOX 12608
AUSTIN, TX 78711
PHONE: (800) 531-5441 extension 3-3010
You have certain rights under Chapters 552 and 559, Government Code, to review, request, and correct information we have on file
about you. Contact us at the address or toll-free number listed on this form.
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