Figure: 7 TAC §90.203(b)(2)(B)

"ITEMIZATION OF AMOUNT FINANCED

1.     Amount financed: (2+3+4-5) $____________

2.     Amount given to me directly $____________

3.     Amount paid on my account (Net Balance - Prior Account) $____________

4.     Amount paid to others on my behalf (A+B+C+D+E+F) $____________
        (You may be retaining a portion of this amount.)
        A.    Cost of personal property insurance paid to insurance company $____________
        B.    Cost of single-interest insurance paid to insurance company $____________
        C.    Cost of optional credit insurance paid to insurance company or companies
                Life $____________
                Disability $____________
                Involuntary Unemployment Insurance $____________
                Total C: $____________
        D.    Non-Filing Insurance paid to insurance company $____________
        E.    Official fees paid to government agencies $____________
        F.     Payable to: __________________ $____________
                Payable to: __________________ $____________
                Payable to: __________________ $____________
                Total F: $____________

5.     Prepaid Finance Charge (Administrative Fee) $____________."