Do not write in the space above
CONTRIBUTION TO TEXAS GRANT AND TEACH FOR TEXAS LOAN REPAYMENT ASSISTANCE PROGRAMS
You may contribute to TEXAS Grant and Teach for Texas Loan Repayment Assistance Programs all or part of the "DISCOUNT" shown on your return by filing the return and paying the tax by the due date. If you wish to contribute to these programs: - Complete your return and calculate the "TOTAL AMOUNT DUE." - 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.
FOR COMPTROLLER'S USE ONLY
T code Deposit code
Taxpayer number (Use the number on your return)
Amount of contribution
Taxpayer or duly authorized agent
City, state, ZIP code
For tax assistance call 1-800-252-5555 toll free nationwide, or call 512/463-4600. 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 toll-free number listed on this form.