Effective Date
Instructions
Updated: 3/2024
Purpose
Form 4103 is used to submit invoice information to Accounts Payable (AP). Complete the form and attach when sending or forwarding an invoice to AP.
Procedure
Fill in all applicable fields. Required fields have red border. The user must first download the form to their desktop then use Adobe Reader or Adobe Pro to open it.
Transmittal
Once you have completed the form, click File, then Save As, and give the completed form a name. Do not use Microsoft Print to PDF.
Attach the completed form, invoice and other applicable documents and send to HHSC AP mailbox.
- Attach form 4103 if sending or forwarding the invoice to AP for the first time.
- Do not attach form 4103 if the invoice and form 4103 were already sent to AP but you are sending more documents.
Detailed Instructions
Invoice Date: The date the vendor entered on the invoice. Use short date format which is mm/dd/yyyy.
Invoice No: The invoice number or invoice id.
Vendor ID (TIN or EIN): The payee or entity’s Texas Identification Number or Employee Identification Number. These numbers should only be 10-digits
Name: The payee or entity’s legal name.
Gross Amount: Total dollar amount on the invoice.
Purchase Order (PO): Purchase order that must be used for the payment. Leave the field blank if not applicable.
Contract: The contract associated with the goods or service. Leave the field blank if not applicable.
Invoice Received Date: The date the invoice was first received at HHSC or the date a revised invoice was received. Use short date format which is mm/dd/yyyy.
Note: The terms payee, entity, and vendor are used synonymously.