Form 14-124 - Texas Motor Vehicle Registration Surcharge And/or Title Application Fee Report

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14-124
b.
(Rev.6-03/2)
TEXAS MOTOR VEHICLE REGISTRATION SURCHARGE
AND/OR TITLE APPLICATION FEE REPORT
DO NOT WRITE IN SHADED AREAS
21100
a. T Code
c. Taxpayer number
d. Filing period
e.
f. Due date
IMPORTANT
h.
g. Name and mailing address (Make any necessary name or address changes below.)
Blacken this box if your mailing
address has changed. Show changes
1.
by the preprinted information.
Blacken this box if you are no
longer in business and write in the
2.
date you went out of business.
Month
Day
Year
i.
j.
INSTRUCTIONS FOR COMPLETING THE
TEXAS MOTOR VEHICLE REGISTRATION SURCHARGE
AND/OR TITLE APPLICATION FEE REPORT
The Texas Motor Vehicle Registration Surcharge and/or Title Application Fee must be remitted to the Texas Comptroller
on a monthly basis. Reports should be filed by the 10th day of the month following the report period.
Prior payments include electronic funds transferred for this report period. Include any collections made on prior dishonored
payments in Item 1.
21100
12100
COLUMN A
COLUMN B
REGISTRATION
TITLE APPLICATION
SURCHARGE
FEE
1A.
1B.
1. Number of registrations and/or title applications
2. Total registration surcharge and/or
$
$
2A.
2B.
title application fees collected
$
$
3A.
3B.
3. Claim for dishonored payment
$
$
4. Total surcharge and/or title application fee due
(Item 2 minus Item 3)
4A.
4B.
Form 14-124 (Rev.6-03/2)
* * * DO NOT DETACH * * *
$
$
5A.
5B.
5. Prior payments
$
$
6A.
6B.
6. Total amount due and payable
(Subtract Item 5 from Item 4)
k.
l.
7. TOTAL AMOUNT OF MOTOR VEHICLE
$
SURCHARGE AND/OR TITLE APPLICATION FEE
7.
DUE AND PAYABLE (Add Item 6A and Item 6B.)
Taxpayer name
m.
T Code
Taxpayer number
Period
I declare that the information in this document and any attachments is true and
21020
correct to the best of my knowledge and belief.
Taxpayer or duly authorized agent
Make check payable to: STATE COMPTROLLER
Mail to: COMPTROLLER OF PUBLIC ACCOUNTS
111 E. 17th Street
Date
Business phone
Austin, Texas 78774-0100
For assistance, call 1-800-252-1382 toll free nationwide. The local number in
Austin is 512-463-4600. From a Telecommunication Device for the Deaf (TDD),
call 1-800-248-4099, toll free. The TDD number in Austin is 512-463-4621.
333 A

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