Form 00-941 - Texnet Payment Form - 2008

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00-941
(Rev.11-07/8)
TEX
ET
CHANGE
Please type.
Payor name (As printed on tax return)
Taxpayer number (As printed on tax return)
Mailing address
Type of tax or fee payment (i.e. Sales, Franchise, Motor Fuel, Motor Vehicle Sales, etc.)
Funds transfer contact
Phone number (Area code, number, extension)
CHANGE THE FOLLOWING :
Effective with next payment due ____ / ___ / ___
METHOD OF PAYMENT:
ACH Debit
BANK INFORMATION (FOR ACH DEBIT METHOD ONLY):
ACCOUNT TYPE
CHECKING
SAVINGS
I hereby authorize the Texas Comptroller of Public Accounts to initiate ACH Debit entries to the financial institution account
indicated below 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 upon it.
Name
Date
Bank name
City, State
Transit/Routing number *
Bank account number
* Please verify with your bank that this is the correct number for electronic transactions, which may be different from the number on your check.
ACH Credit with Addenda
For assistance in completing this form, contact the TEXNET Hotline at (800) 531-5441, ext. 3-3010.
PLEASE COMPLETE AND RETURN THIS FORM TO:
FAX: (512) 463-1364
or
COMPTROLLER OF PUBLIC ACCOUNTS
Cash & Securities Management Division
Cash Management Programs
P.O. Box 12608
Austin, Texas 78711-2608
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
toll-free number listed on this form.

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