ACCOUNT NUMBER          QTR YR 
                                      
                     Q/YR
 
                                         MONTH    DAY        YEAR              INITIALS 
 
 PAYMENT VOUCHER                      FOR TWC USE ONLY 
 
 EMPLOYER NAME
 
                                      CASHIER 

  Remittance Amount                   TEXAS WORKFORCE COMMISSION 
                                      P.O. BOX 149037 
                                      AUSTIN, TX 78714-9037 
 
FORM C-3V INTERNET (0306)             INTERNET PAYMENT VOUCHER