Form 40-116 - District Clerk Filing Fees - Monthly Report
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140-116
REPORT MUST BE FILED EVEN IF NO PAYMENT IS DUE
(Rev. 9-97/10)
b.
DISTRICT CLERK FILING FEES - MONTHLY REPORT
38110
DO NOT WRITE IN SHADED AREAS
a. T Code
c. County identification number
County name and mailing address
d.
If any information
pre-
printed on this form is
incorrect,
cross out the
incorrect information and
write in the correct infor-
mation.
e. Due date of report
g.
h.
f. Report for month ending
i.
1. Amount of fees collected for cases assigned to statutory county court
1.
($40.00 for a filing transferred to statutory county court originally filed in district court)
2. Amount of district clerk filing fees collected
2.
($40.00 for each filing in district court)
3. Total amount of fees collected
(Item 1 plus Item 2)
3
* * * DO NOT DETACH * * *
4. TOTAL AMOUNT OF PAYMENT
(Same as Item 3)
4.
j.
k.
County name
For assistance call 1-800-531-5441, ext. 3-4276, toll free nationwide. The Austin number is 512/463-4276.
T Code
County identification no.
Period
(From a Telecommunication Device for the Deaf (TDD), call 1-800-248-4099, toll free.
The Austin TDD number is 512/463-4621.)
38030
I,
(type or print name)
_____________________________________________________, certify
that the information above is true as shown in the records of the District Clerk of the county named.
Complete this report and make the amount in Item 4 payable to:
Authorized agent
STATE COMPTROLLER
COMPTROLLER OF PUBLIC ACCOUNTS
Mail to:
Title
Date
111 E. 17th Street
Daytime phone number
(Area code and number)
Austin, Texas 78774-0100
Form 40-116 (Rev. 9-97/10)
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Parent category: Financial