FORM C-803 (03/2019) MANUAL NOTICE OF PAYMENT OF DEFAULT NOTICE TO RETAILER, MIXED BEVERAGE OR PRIVATE CLUB PERMITTEE: This notice of payment does not constitute a release from the delinquent list. You may not purchase alcoholic beverages until your permit/license number has been released from the DELINQUENT LIST. DATE: PLEASE (X) THE FOLLOWING DELIVERY PERIOD: Month: N/A 1 - 15 OR 16 - 31 TRADENAME: PERMIT NUMBER: OWNER: LOCATION ADDRESS: DATE OF PAYMENT: AMOUNT PAID: NOTE: The delinquent amount paid must match the AMOUNT UNPAID reported on the Notice of Default in order to RELEASE THE DEFAUL. Name of Wholesaler , Brewery, Brewpub, or Local Distributor Permittee Street Address City Representative222s Signature Title This Notice of Payment must be mailed to the appropriate Regional Audit Office Listed Below: Region 1 226 500 Chestnut Street, Ste. 1573, ABILENE, Texas 79602 226 Fax (325) 670-9838 Region 2 226 2225 East Randol Mill, Ste. 200, ARLINGTON, Texas 76011 226 Fax (817) 607-2492 Region 3 226 427 West 20th Street, Ste. 600, HOUSTON, Texas 77008 226 Fax (713) 426-7979 Region 4 226 7700 Chevy Chase Drive, Ste. 200, AUSTIN, Texas 78752 226 Fax (512) 451-0240 Region 5 226 4203 Woodcock Drive, Ste. 120, SAN ANTONIO, Texas 78228 226 Fax (210) 731-1759 NOTE : Copy of Notice should be mailed to the Mixed Beverage or Private Club Permit Holder. American LegalNet, Inc. www.FormsWorkFlow.com