Appli for Tx ID Number / Additional Mailing Address



| |Doc. Type |Doc. No. |ISAS Update Only | |

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This application must be submitted by every person (sole owner, individual recipient, partnership, corporation, or other organization) who intends to bill the Texas Department of Family and Protective Services for goods, services provided, refunds, public assistance, etc.

Your Texas Identification No. (TIN) will be required on all vouchers submitted by any state agency. Your use of this TIN on all billings will reduce the time required to process your billings to the State of Texas.

For assistance in completing this application, call the FPS Accounting Division at (512) 438-2401.

Please DO NOT write in shaded boxes (these areas are for Accounting Division use).

Please DO NOT use dashes when entering Social Security, Federal Employer’s Identification (FEI), or Comptroller’s assigned numbers.

Disclosure of your Social Security No. is authorized under the law (Op. Tex. Att’y., Gen. No. H-1225 [1978]).

Please TYPE or PRINT all entries.

|New Account (initial set up) |Mail Code |

| Yes (Mail Code 000) No |    (3 digits) |

I. TEXAS IDENTIFICATION NUMBER - The number you provide in this section will be used to report payments to the IRS, if applicable.

|Indicate type of number you are providing to be used for your TIN by checking the appropriate box below: |

| 1 - Federal Employer’s Identification (FEI) No. | 3 - Comptroller’s assigned number | |Enter the number: | | |

| 2 - Social Security Number | | |      (9 or 11 digits) | | |

| | | |

| | | |

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| Check box if agency representative to be notified of assigned TIN by mail at mail code entered in Section VIII. |

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|II. PAYEE INFORMATION - (maximum 50 characters, including spaces, per line in this section.) |

|Name of Payee (individual or business to be paid) |

|      |

|Mailing Address (where you want to receive payments) |

|      |

|2nd Line Address (if required) |

|      |

|3rd Line Address (if required) |

|      |

|4th Line Address (if required) |

|      |

|City |State |Zip + 4 |County |

|      |   |      |      |

|Business Telephone No. |A/C and Number | |SIC Code |Security Type |Zone |

|(area code and number): |      (10 digits) | | | 0 1 2 | |

|Are you currently reporting any Texas tax other | |If “Yes”, enter Texas Taxpayer No. |

|than unemployment (E.G., sales tax, franchise tax)? | Yes No |      (11 digits) |

III. BUSINESS INFORMATION (for statistical reporting) - Please check all categories that apply to your business. PROVIDING THE INFORMATION REQUESTED IN THIS SECTION IS VOLUNTARY.

Small Business Enterprise (independently owned and operated with fewer than 100 employees or less than $1,000,000 annual gross receipts)

Disadvantaged Business Enterprise (at least 51% owned or controlled by one or more socially disadvantaged persons) - Check the appropriate category:

Black Hispanic American Indian Asian American Eskimo Aleut Other (specify);      

Woman Owned Business Enterprise (at least 51% owned or controlled by women)

Other Business Enterprise (an enterprise not described in one of the three categories shown above) FPS USE ONLY

| | Bus. Desc. |

IV. OWNERSHIP CODES (For Initial Set-up only) - Check ONLY ONE code by the appropriate ownership type that applies to you or your business and enter any required additional information.

| I-Individual Recipient (not owning a business) |

| |Agency No. |

| E-State Employee - Enter agency number of employing agency: |    (3 digits) |

| |

| S-Sole Ownership of Business - Enter owner’s name and Social Security No. |

|Owner’s Name |Social Security No. | |

|      |2       (9 digits) | |

| |

|P- Partnership - Enter two partner’s names and SSN’s. If partner is corporation, use corporation’s Federal Employer’s Identification (FEI) number. |

|Partner 1 - Name | |SSN / FEI | |

|      | |      (9 digits) | |

|Partner 2 - Name | |SSN / FEI | |

|      | |      (9 digits) | |

| |

|T- Texas Corporation Enter Tx Charter No. (If T, A, or C is checked) |

| |Texas Charter No. |

| A- Professional Association Enter Tx Charter No. (If T, A, or C is checked) |      (10 digits) |

| |

| C- Professional Corporation Enter Tx Charter No. (If T, A, or C is checked) |

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| O- Out-of-state Corporation |

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| G- Government Entity |

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| U- State Agency / University |

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| F- Financial Institution |

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| R- Foreign (out of U.S.A.) |

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| N- Other (explain):       |

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|V. PAYMENT ASSIGNMENT INFORMATION (NOTE: A copy of the assignment agreement between payees must be attached.) |

|Assignee Name | |Assignee TIN | |Assignment Date |

|      | |      (9 digits) | |      (6 digits) |

| |

|VI. COMMENTS:       |

| |

|VII. APPLICANT INFORMATION |

|Applicant or Authorized Agent |Telephone No. (inc. A/C) |Date |

|      |      |      |

| |

|VIII. FPS REPRESENTATIVE INFORMATION |

|FPS Representative |Telephone No. (inc. A/C) |FPS Mail Code |

|      |      |      |

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