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Payment Services Forms (Numerical)

Name Number Description
Debtor Hold File Extract Request (login required)
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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.
Employee PayCard Authorization (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).