Please complete and sign this report and enter
40-138
a telephone number that can be called if
(Rev.7-03/3)
b.
additional information is necessary.
CHILD SAFETY SEAT AND SEAT BELT
TERTIARY CARE FUND
VIOLATION FINES -
32170
a. T Code
c. City/County Identification Number
d. Report for fiscal year ending
e.
f. Due date of report
City/County name and mailing address
g.
IMPORTANT
h.
Blacken this box if your address
has changed. Show changes by
1
the preprinted information.
i.
j.
Under Ch. 559, Government Code, you are entitled to review, request, and correct information we have on
Please check if fiscal year has
file about you, with limited exceptions in accordance with Ch. 552, Government Code. To request information
changed from previous report
for review or to request error correction, contact us at the address or toll-free number listed on this form.
REPORT MUST BE FILED EVEN IF NO PAYMENT IS DUE.
DO NOT WRITE IN SHADED AREAS.
Transportation Code, Sections 545.412 (h) and 545.413 (b) and (j)
Not withstanding Section 542.402(a), a municipality or county, at the end of the municipality or county's
fiscal year, shall send to the Comptroller an amount equal to 50 percent of the fines collected by the
municipality or the county for violations of sections 545.412 and 545.413 (b). The Comptroller shall
deposit the amount received to the credit of the Tertiary Care Fund for use by trauma centers.
Municipal and county officials should use this form to submit payment of 50 percent of the fines collected
on these violations during their fiscal year. This report is due 30 days after the end of the city or county's
fiscal year.
$
1. TOTAL AMOUNT OF FINES COLLECTED
1.
X .50
2. TOTAL AMOUNT OF FINES DUE THE STATE (Multiply amount in Item 1 by .50)
2.
* * * DO NOT DETACH * * *
$
3. TOTAL AMOUNT OF PAYMENT (Same as Item 2)
3.
City/County name
k.
l.
T Code
Identification no.
Period
For assistance call 1-800-531-5441, ext. 3-4276, toll free nationwide. The Austin
number is 512/463-4276.
32060
(From a Telecommunications Device for the Deaf
(TDD), call 1-800-248-4099, toll free. The Austin TDD number is 512/463-4621.)
I, (type or print name) __________________________________________________ certify
Complete this report and make the amount in Item 3 payable to:
that the information above is true as shown in the records of the city or county named.
STATE COMPTROLLER
Authorized agent
Mail to: COMPTROLLER OF PUBLIC ACCOUNTS
111 E. 17th Street
Title
Date
Austin, Texas 78774-0100
Daytime phone (Area code and number)
40-138 (Rev.7-03/3)
1
