Form 40-149 - Child Safety Seat Monthly Court Costs Payment
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140-149
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CLEAR FIELDS
(10-09)
CHILD SAFETY SEAT
MONTHLY COURT COSTS PAYMENT
City / County name
Identification number
Contact name
Phone (Area code and number)
Year
Month
(select month)
$
Amount of payment ...................................................................................................
_________________
Complete this form and make the amount payable to:
STATE COMPTROLLER
Mail to: COMPTROLLER OF PUBLIC ACCOUNTS
P.O. Box 149361
Austin, TX 78714-9361
For assistance, call (800) 531-5441, ext. 3-4276, or (512) 463-4276.
DETACH AND RETURN THE BOTTOM PORTION ONLY.
KEEP THE TOP PORTION FOR YOUR RECORDS.
40-149
(10-09)
CHILD SAFETY SEAT
MONTHLY COURT COSTS PAYMENT
Amount of
City / County name
$
payment ...............
Taxpayer number
Month
Year
Contact
Phone (Area code and number)
(select month)
Tcode
Dep
Taxpayer no.
Amt.
90100
710
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Parent category: Financial