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Payment Services Forms (Alphabetical)

The forms listed below are PDF files. They include graphics, fillable form fields, scripts and functionality that work best with the free Adobe Reader. While other browsers and viewers may open these files, they may not function as intended unless you download and install the latest version of Adobe Reader.

Name Number Description
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.
Agency Authorization for Warrant Pickup (login required) PDF 74-189 Used by agencies to authorize personnel to pick up warrants.
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).
Application to Report Indebtedness (login required) PDF 74-188 Used by agencies requesting to report state debts or change existing hold agency information.
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
Debtor Hold File Extract Request (login required) -- Used by agencies to request the daily debtor hold extract file.
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.
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.
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.
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.
PayCard Enrollment Authorization (login required)PDF 74-224 This form is used by employees to sign up to receive payroll payments through the Employee PayCard program.
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.
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.
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.
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.
Warrant Release or Reinstatement Request (login required) PDF 00-432 Used by a hold source agency to authorize the release of a held warrant.

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