Form Ap-197-1/4 - Texas Dyed Diesel Fuel End User
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4Texas Dyed Diesel Fuel End User
Signed Statement Number Registration
G L E N N H E G A R
T E X A S C O M P T R O L L E R O F P U B L I C A C C O U N T S
GENERAL INFORMATION
Who Must Submit This Registration - You must submit this registration if you are a sole owner, partnership, corporation or other
organization; you are located in Texas; and you want to purchase tax-free dyed diesel fuel for off-highway use by issuing a
signed statement to your supplier or distributor. You must obtain an End User Number from the Comptroller’s office.
For Assistance - If you have any questions regarding this registration, filing tax returns or any other tax-related matter, you may contact
the Texas State Comptroller’s fi eld office in your area or call 1-800-252-1383.
General Instructions -
• Type or print in ink.
• Please do not separate pages.
• Write only in white areas.
• Complete this application and mail to
Comptroller of Public Accounts
111 E. 17th Street
Austin, TX 78774-0100
Federal Privacy Act - Disclosure of your Social Security number is required and authorized under law, for the purpose of tax admin-
istration and identifi cation of any individual affected by applicable law. 42 U.S.C. §405(c)(2)(C)(i); Tex. Govt. Code §§403.011 and
403.078. Release of information on this form in response to a public information request will be governed by the Public Information
Act, Chapter 552, Government Code, and applicable federal law.
You have certain rights under Chapters 552 and 559, Government Code, to review, request and correct information we have on file
about you. Contact us at the address or phone numbers listed on this form.
SPECIFIC INSTRUCTIONS
Item 1 - Sole Owner: Enter the fi rst name, middle initial and last name.
Item 4 - Other Organization: Explain the type of organization. Examples: Social Club, Independent School District, Family
Trust.
Item 5 - Partnership: Enter the legal name of the partnership.
Corporation: Enter the legal name exactly as it is registered with the Secretary of State.
Other Organization: Enter the title of the organization.
Items 3 & 6 - If you have both a Texas taxpayer number and a Texas Identifi cation Number, enter the fi rst 11 digits of the Texas Iden-
tifi cation Number.
Item 7 - Enter the Federal Employer Identifi cation Number (FEIN) assigned to your business by the Internal Revenue Service.
Item 9 - Enter the complete mailing address where you wish to receive mail from the Comptroller of Public Accounts. If you wish
to receive mail at a different address for other taxes, attach a letter with the other addresses.
Item 13 - Texas Corporation: Enter the fi le number assigned by the Secretary of State and date of formation.
Item 14 - Foreign Corporation (chartered out of Texas): Enter the state or country of formation, the charter/fi le number and date,
and the Texas Secretary of State fi le number and date.
Item 16 - Limited Partnership: Enter the state in which the partnership is registered and the limited partnership number issued
by the Secretary of State.
Item 17 - Partnership: Enter information for all partners.
If the applicant does not have a Social Security number, enter the Individual Taxpayer Identifi cation Number (ITIN) or
other number assigned by the federal government for use when fi ling federal income tax returns.
Corporation or Other Organization: Enter information for the principal officers (president, vice-president, secretary).
Item 19 - Enter the actual location of your business—street address or meaningful directions. Example: “3 miles south of FM 1960
on Jones Road.” Do not use a P.O. Box or Rural Route number.
AP-197-1 (Rev.5-15/13)
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