89-123
        (12-20)                                                                                                   PRINT FORM CLEAR FIELDS

Credit Memo Acceptance

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.
Name of purchaser, firm or agency accepting credit memo

Address (Street address, P.O. Box or Route number)                           Daytime phone (Area code and number)

City                                                            State                                     ZIP code

     I, as the authorized representative for the party named above, accept credit memo number  _________________

     dated  _______________________  in the amount of $ _________________ . This credit memo was issued to us

     by _________________________________________________________ , our vendor, to cover  ___________                          tax 
                                                                                                                     Tax type*
     collected from us on invoice number(s) __________________________________________________________ ,

     by the vendor, dated ________________________________________________________________________                            .

     I understand that this credit memo is being issued in lieu of a cash refund from the vendor or the State of Texas and 

     will be credited against my account with the vendor. This credit memo is accepted in full and final settlement of the 

     refund due to us for   ___________                 tax regardless of any subsequent actions taken by the vendor.
                           Tax type*

                                                        __________________________________________________
                                                       Print or type name

                                                        __________________________________________________
                                                       Relationship to Entity (i.e., President, Treasurer)

                                                        __________________________________________________
                                                       Signature

                                                        __________________________________________________
                                                       Date

     * Tax Type  - Please include the type of tax or fee you were charged. This form may be used for any taxes or fees paid in error and for which a 
     refund may be approved, e.g., limited sales, excise, and use tax; oil well service tax; miscellaneous gross receipts tax. This form cannot be used 
     for motor vehicle tax.

                           For more information on refunds, please visit www.comptroller.texas.gov/taxes/refunds/