Texas Department of Insurance
Legal & Compliance, Mail Code 110-1A
333 Guadalupe • P. O. Box 149104, Austin, Texas 78714-9104 512-475-1821 telephone • www.tdi.state.tx.us
C O N T A C T
Monetary Forfeiture Notice
Important: Attach this notice to your check or money order and mail to:
S E C T I O N
Texas Department of Insurance Attn: Legal Services, Division 811, MC 9999 P.O. Box 149104 Austin, Texas 78714-9104 Returning this Monetary Forfeiture Notice with your payment will ensure accurate accounting.
NAME
CASE NUMBER
ORDER NUMBER
LC153 Rev. 10/04
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