Payment Services Forms (Numerical)
Note: Forms must be downloaded and opened using Adobe Acrobat Reader if you want to fill them out electronically.
Do not fill out forms using your internet browser.
| Form Name | Number | Description |
|---|---|---|
| Debtor Hold File Extract Request (login required) | -- | Used by agencies to request the daily debtor hold extract file. |
| Warrant Release or Reinstatement Request (login required) PDF | 00-432 | Used by a hold source agency to authorize the release of a held warrant. |
| Payment Cancellation Voucher (login required) PDF | 73-179 | Used by agencies to request cancellations of forged warrants that are reinstated or for post-dated payroll deduction warrants. |
| Hold Transaction (login required) PDF | 74-154 | Used by a hold source agency to set up, change or release hold information for a state debtor. |
| Payee Change Request (login required) PDF | 74-157 | Used by agencies requesting updates to payee information in the Texas Identification Number System (TINS); may be provided by the agencies to their payees. |
| Direct Deposit Authorization Form (login required) PDF | 74-176 | Used by agencies to provide to payees who wish to receive state payments by direct deposit or change/cancel existing direct deposit information. |
| Application to Report Indebtedness (login required) PDF | 74-188 | Used by agencies requesting to report state debts or change existing hold agency information. |
| Agency Authorization for Warrant Pickup (login required) PDF | 74-189 | Used by agencies to authorize personnel to pick up warrants. |
| Bailment Contract (login required) PDF | 74-190 | Used as an agreement between a state agency and the Comptroller’s office that allows the agency to receive post-dated payroll warrants before payday |
| Direct Deposit Reversal Request (login required) PDF | 74-191 | Used by agencies to request an erroneous direct deposit payment be reversed through the Automated Clearing House (ACH) system. |
| Summary Number Application (login required) PDF | 74-216 | Used by agencies to apply for a special payee identification number for low dollar, one-time payments to multiple payees. |
| Tax Refund Direct Deposit Authorization (login required) PDF | 74-221 | Used by the Comptroller’s Revenue Accounting Division to provide to taxpayers who wish to receive tax refund payments by direct deposit. |
| Pay Card Enrollment Authorization – Employees (login required)PDF | 74-224 | This form is used by employees to sign up to receive payroll payments through the Employee PayCard program. |
| Reclamation Request for ACH Transactions (login required) PDF | 74-226 | Used by a agencies upon notification of a payee’s death to reclaim a pension, annuity or benefit payment made by direct deposit for which the payee or its estate was not entitled. |
| ACH (Direct Deposit) Payment Destination Confirmation (login required) PDF | 74-227 | Used by agencies who must require payees to confirm whether their state payments are destined to be forwarded outside of the U.S. |
| Direct Deposit Payment Trace Number Request (login required) PDF | 74-229 | Used by agencies to request an ACH trace number for a state direct deposit payment. |
| Application for Texas Identification Number (login required) PDF | AP-152 | Used by agencies to obtain necessary information from payees to set up a Texas Identification Number (TIN). |