
74-221
(Rev.9-15/12)
For Comptroller’s use only
Enter your 11-digit Texas taxpayer number Business phone (Area code and number)
ext.
Business name
Mailing address City State ZIP code
Taxpayer Information
SECTION 1
Tax Refund Direct Deposit Authorization
This form may be used by taxpayers receiving
tax refund payments from the State of Texas.
Please return your completed form via mail or FAX to:
Texas Comptroller of Public Accounts
Fiscal Management – Direct Deposit Program
P.O. Box 13528
Austin, TX 78711-3528
Help line: 512-936-8138
FAX: 512-475-5424
SECTION 8
Form Return Information
SECTION 2
Tax Type (Required)
Cigarette/Tobacco (T88)
Franchise (T13)
Insurance Premium (T71)
Motor Vehicle Rental (T15)
Seller Finance (T70)
Crude Oil (T36)
Hotel (T75)
CNG / LNG (T90)
Motor Vehicle Sales (T00)
Other:
Diesel/Motor Fuel Claim (T00)
IFTA (T56)
Mixed Beverage Sales (T63)
Natural Gas (T37)
Other:
Diesel/
Insura
Mixed
Sales
Motor
nce Mai
Bevera
(T26)
Fuel Tax (T90)
ntenance (T72)
ge Gross Receipts (T73)
Place an X beside the appropriate tax type(s).
(Mandatory)
SECTION 6
........................................................... YES NO
Please note: Your direct deposit will not be set up if box is not checked.
New setup
Change account number
C
C
hange ac
ancellatio
Transaction Type
SECTION 3
count type
n
Authorization for Setup, Changes or Cancellation (Required)
SECTION 7
Authorized signature Printed name Date
I understand that the Texas Comptroller of Public Accounts will reverse any payments made to my account in error.
I further understand that the Texas Comptroller of Public Accounts will comply at all times with the National Automated Clearing House Association's
rules.
Financial institution name City State
Routing transit number (9 digits) Customer account number Type of account
Checking Savings
Financial representative name (optional) Title (optional)
Financial representative signature (optional) Phone number (optional) Date (optional)
New Account Information (Setups and Changes)
SECTION 4
ext.
SEC 5
Routing transit number (9 digits) Customer account number Type of account
Checking Savings
Existing Account Information (Changes Only)
*7422100W091512*
*7422100W091512*
* 7 4 2 2 1 0 0 W 0 9 1 5 1 2 *