25-107
(Rev.5-13/17)
Texas Automobile Burglary and Theft Prevention
Authority Assessment Semi-Annual Payment Worksheet
(Licensed Companies and Miscellaneous Organizations)
b. Filing period
d. Due date
a. Taxpayer number
c.
e. Taxpayer name and tax report mailing address
Taxpayers with no payments due or taxpayers
making payments by electronic fund transfers
are NOT required to file this form.
For information about Insurance Tax, contact the
Texas Comptroller's field office in your area or call
1-800-252-1387 or 512-463-4600. Details are also
available online at
NOTE: Insurers may recoup this assessment from policyholders as authorized by 28 TAC, Section 5.205.
Specific Information for Questions Regarding the Assessment -
All requests for information other than form completion should be referred to
the Automobile Burglary and Theft Prevention Authority at 1-888-368-4689 or
512-465-4011, or by writing to:
Electronic reporting and payment options are
Automobile Burglary and Theft Prevention Authority
available 24 hours a day, 7 days a week.
c/o Texas Department of Motor Vehicles
Have this form available when you log on.
4000 Jackson Avenue
Austin, TX 78731-6007
Additional instructions are on the reverse side.
CALCULATION
1. Total number of motor vehicle years for policies
effective Jan. 1 - June 30, current year
1.
2. Assessment rate
2.
3. TOTAL AMOUNT DUE AND PAYABLE (Multiply Item 1 by Item 2)
3.
DETACH BELOW AND KEEP THE UPPER PART FOR YOUR RECORDS
RETURN ONLY THIS PART WITH YOUR PAYMENT
Form 25-107 (Rev.5-13/17)
Texas Automobile Burglary and Theft Prevention
Authority Assessment Semi-Annual Payment
4. TOTAL AMOUNT DUE AND PAYABLE (See Item 3)
4.
Taxpayer name
e.
f.
T Code
Taxpayer number
Period
I declare the information in this document and all attachments is true and correct
to the best of my knowledge and belief.
Authorized agent
Preparer's name (Please print)
Make the amount in Item 4
Mail to: COMPTROLLER OF PUBLIC ACCOUNTS
payable to:
P.O. Box 149356
Daytime phone
Date
STATE COMPTROLLER
Austin, TX 78714-9356
(Area code & number)
You have certain rights
under Chapters 552 and 559, Government Code,
to review, request and correct information we have on file about you.
111 A
Contact us at the address or phone number listed on this form.
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