Form 40-150 - Scrap Metal Theft Grant Program Quarterly Fine Collections
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140-150
(12-11)
Scrap Metal Theft Grant Program
Quarterly Fine Collections
City or County name
Identification number
Contact name
Phone (Area code and number)
Calendar quarter
Year
(select quarter)
For fines collected on convictions under Occupations Code Section 1956.040, Section (a-1).
$
1. Total fines collected this calendar quarter .........................................................
_________________
$
2. Service fee retained (10% of fine amount collected) .........................................
_________________
$
3. Amount due / paid (Line 1 minus Line 2) ...........................................................
_________________
List name of business/individual and case/docket number from each collected fine reported on Line 1
NAME
CASE/DOCKET
AMOUNT
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 1-800-531-5441, ext. 3-4276, or 512-463-4276.
Do Not Detach — Mail entire form with payment (Keep a copy for your records.)
40-150
(12-11)
Scrap Metal Theft Grant Program
Quarterly Fine Collections
Amount of
City or County name
$
payment ...............
Identification number
Quarter
Year
Contact
Phone (Area code and number)
(select quarter)
Tcode
Dep
Taxpayer no.
Amt.
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Parent category: Financial