Vernon's Texas Rules Annotated - VTRA TX R PARENT NOT Form 2G . CLERK’S CERTIFICATION OF COURT COSTS AND FEES AND TRANSMISSION OF ORDER FOR PAYMENT IN PROCEEDING TO WAIVE PARENTAL NOTIFICATION AND CONSENT

Director, Fiscal Division

Texas Department of Health

1100 West 49th Street

Austin TX 78756

Dear Sir or Madam:

Please find enclosed a certified copy of an Order issued on __________, 20 ___, in the referenced case. Please pay the amounts to the payees as stated in the Order.

In accordance with the Order, I certify the following fees and costs for payment as follows:

Amount: $

Name of the Clerk:

Address:

Tax Identification No.:

Thank you.

[seal]

Encl.: Certified copy of Order