00-213                                                                                                              PRINT FORM                CLEAR FIELDS
        (Rev.3-15/9)                                                                                         *0021301W031509* 
                                                                                                             *0021301W031509*MAILING INSTRUCTIONS
Contribution to Texas Grant and Teach for                                                                      *   0   0      2   1   3   0   1 W      0   3   1   5   0   9 *  
Texas Loan Repayment Assistance Programs                                                                                        FOR COMPTROLLER’S            USE ONLY 
                                                                                                                                    T code 
You may contribute to TEXAS Grant and Teach for Texas Loan Repayment Assistance Programs all or part of the                                                  90100 
“DISCOUNT” shown on your return by filing the return and paying the tax by the due date.                                            Deposit code             540 
If you wish to contribute to these programs:                                                                             Taxpayer number
-  Complete your return and calculate the “TOTAL  AMOUNT DUE.”                                                           (Use the number on your return) 
-  Enter the information requested on this form and show the amount of discount you wish to contribute. 
-  Make your payment payable to STATE COMPTROLLER for the TOTAL of the amount due on your return 
PLUS the amount contributed.
-  Return this form with your tax return and payment to the COMPTROLLER.                                                 Amount of contribution 
Taxpayer name                                                                                                               $ 
Address                                                                                                              Taxpayer  or duly authorized agent 

City, state, ZIP code                                                                                       Business phone                      Date 

                                             For tax assistance call 1-800-252-5555. 
               You have certain rights under Chapters 552 and 559, Government Code, to review, request and correct information we have on file about you. 
                                             Contact us at the address or phone number listed on this form.