Form Ap-197-1/4 - Texas Dyed Diesel Fuel End User Page 3

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*AP19730W051513*
AP-197-3
PRINT FORM
CLEAR FORM
(Rev.5-15/13)
*AP19730W051513*
Texas Dyed Diesel Fuel End User
*
A
P
1
9
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W
0
5
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Signed Statement Number Registration
Page 1
• Type or print in ink.
• Do not write in shaded areas.
SOLE OWNER IDENTIFICATION
1. Name of sole owner (First, middle initial and last name)
3. Taxpayer number for reporting any Texas tax OR Texas Identification
2. Social Security number (SSN)
Check here if you DO NOT
Number if you now have or
have a SSN.
have ever had one.
NON-SOLE OWNER IDENTIFICATION
--- ALL SOLE OWNERS SKIP ITEMS 4 - 8 ---
4. Business organization type
Texas registered limited liability partnership (PX)
Texas limited liability company (CL)
Non-Texas limited liability company (CI)
Estate (ES)
Non-Texas registered limited liability partnership (PY)
Texas profit corporation (CT)
Non-Texas profit corporation (CF)
Professional corporation (CP)
General partnership (PB, PI)
Texas nonprofit corporation (CN)
Non-Texas nonprofit corporation (CM)
Professional association (AP)
Limited partnership (PL or PF)
Trust (FM or TR) (Please submit a copy of the trust agreement with this application.)
Other (explain)
5. Legal name of partnership, company, corporation, association, trust or other (Do not list DBA.)
6. Taxpayer number for reporting any Texas tax or Texas Identification Number if you now have or have ever had one ....
7. Federal Employer Identification Number (FEIN) assigned by the Internal Revenue Service ...............................................
8.
Check here if you do not have a FEIN . .........................................................................................................................
9. Mailing address
Street number, P.O. Box or rural route and box number
City
State/province
ZIP code
County (or country, if outside the U.S.)
10. Name of person to contact regarding day to day business operations
Daytime phone
11. Principal type of business
Agriculture
Transportation
Retail Trade
Real Estate
Mining
Communications
Finance
Services
Construction
Utilities
Insurance
Public Administration
Manufacturing
Wholesale Trade
Other (explain)
12. Primary business activities and type of products or services to be sold
SIC
If you are a SOLE OWNER, skip Items 13 - 17.
File number
Month
Day
Year
13. If the business is a Texas profit entity, nonprofit entity, professional entity
or limited liability company, enter the file number and date. .............................................................
14. If the business is a non-Texas profit entity, nonprofit entity, professional entity or limited liability company, enter the state or country of formation,
charter/file number and date, Texas Secretary of State file number and date.
State/country of formation
Charter/fi le number
Month
Day
Year
Texas Secretary of State fi le number
Month
Day
Year
15. If the business is a entity, have you been involved in a merger within the last seven years? .......
YES
NO
(If “YES,” attach a detailed explanation.)
State
Number
16. If the business is a limited partnership or registered limited liability
partnership, enter the home state and registered identifi cation number. ..........................................................
17. General partners, principal members/officers, managing directors or managers
(ALL GENERAL PARTNERS MUST BE LISTED - Attach additional sheets, if necessary.)
Name
Title
Phone (Area code and number)
Home address
City
State
ZIP code
SSN or ITIN
Driver license number
State
County (or country, if outside the U.S.)
Percent of
ownership ________ %
Position held
Partner
Officer
Director
Corporate stockholder
Record keeper
Name
Title
Phone (Area code and number)
Home address
City
State
ZIP code
SSN or ITIN
Driver license number
State
County (or country, if outside the U.S.)
Percent of
ownership ________ %
Position held
Partner
Officer
Director
Corporate stockholder
Record keeper
NEXT PAGE

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