Marriage License Fees Form - County Clerk'S Monthly Report - 2009
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1Please complete and sign this report and enter
a telephone number that can be called if
40-117
REPORT MUST BE FILED EVEN IF NO PAYMENT IS DUE
(Rev.9-01/9)
additional information is necessary.
b.
MARRIAGE LICENSE FEES -
COUNTY CLERK'S MONTHLY REPORT
38120
a. T Code
DO NOT WRITE IN SHADED AREAS
c. County identification number
County name and mailing address
d.
If any information preprinted on
this form is incorrect, cross out
the incorrect information and
write in the correct information.
e. Due date of report
g.
h.
f. Report for month ending
i.
1. Number of marriage licenses issued
1.
.
$
2. Marriage license fees due
(Multiply Item 1 by $15.50.)
2.
(Local Government Code, Section 118.018(c), $3 of each marriage
license fee will be deposited into the Family Trust Fund)
3. Number of declarations of informal marriage issued
3.
.
$
4. Declaration fees due
(Multiply Item 3 by $12.50)
4.
.
$
5. Total amount collected for payment to Comptroller
(Total of Items 2 and 4)
5.
* * * DO NOT DETACH * * *
.
$
6.
6. TOTAL AMOUNT OF PAYMENT
(Same as Item 5)
j.
k.
County name
For assistance call 1-800-531-5441, ext. 3-4276, toll free nationwide. The Austin number is 512/463-4276.
T Code
County identification no.
Period
(From a Telecommunication Device for the Deaf (TDD), call 1-800-248-4099, toll free.
The Austin TDD number is 512/463-4621.)
38040
I, (type or print name) __________________________________________________________, certify
that the information above is true as shown in the records of the County Clerk of the county named.
Authorized agent
Complete this report and make the amount in Item 6
payable to:
STATE COMPTROLLER
Mail to:
COMPTROLLER OF PUBLIC ACCOUNTS
Title
Date
111 E. 17th Street
Daytime phone (Area code and number)
Austin, Texas 78774-0100
40-117 (Rev.9-01/9)
222 A
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