
Who Must Submit This Application -
This application must be submitted by every person (sole owner, individual recipient, partnership, corporation or other organization)
who intends to bill agencies of the state government for goods, services provided, refunds, public assistance, etc. The Texas
Note: To expedite processing of this application, please return the completed application to the state agency with which
you are conducting business. It is not necessary for the payee to sign or complete this form. The state agency
representative may complete the form for the payee.
For Assistance -
Notice to State Agnecies -
When this form is used to set up additional mail codes, Sections 1, 2 and 5 must be completed. State agencies may refer to the
General Instructions -
Section 2 - Payee Information
.
Section 3 - Ownership Codes
Section 4 - Payment Assignment
completely and include a copy of the assignment agreement between the assignee and the assignor.
or phone numbers listed on this form.
Fiscal Management