Form Ap-140 Texas Application For Duplicate Coin-Operated Machine Tax Permit(S)

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AP-140

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(Rev.11-07/8)

TEXAS APPLICATION FOR

You have certain rights under Chapters 552 and 559, Government Code,

to review, request and correct information we have on file about you.

DUPLICATE COIN-OPERATED MACHINE TAX PERMIT(S)

1. I hold one of the following: (Check one)

Texas taxpayer number

REGISTRATION CERTIFICATE

GENERAL BUSINESS LICENSE

2. Legal name of machine owner (Sole owner, partnership, corporation or other name)

Check here if there has been a change in your mailing address. Enter the correct address.

Machine owner’s mailing address

Street name and number, P.O. Box or Rural Route and box number

City

State

ZIP code

County

4. Were the tax permit(s) lost, stolen or destroyed? (Check the appropriate box.) ...............................

LOST

STOLEN

DESTROYED

Explain briefly how permit(s) were lost or destroyed. ___________________________________________________________________________

____________________________________________________________________________________________________________________

THE FEE FOR EACH DUPLICATE PERMIT IS $5.00.

5 List the number of each tax permit to be replaced. (Include serial number/inventory number, machine make and machine type.)

LOST, STOLEN OR

MACHINE SERIAL

DESTROYED

NUMBER / INVENTORY

MACHINE MAKE OR MANUFACTURER

MACHINE TYPE CODE

(Use letter code from below)

PERMIT NUMBER

I.D. NUMBER

10.

- PHONOGRAPH

- POOL TABLE

- PINBALL GAME

- VIDEO GAME

- DART

- OTHER

If additional space is needed, add supplemental page. COMPUTER PRINTOUT MAY BE USED.

6. Total number of duplicate occupation tax permits requested.. ...........

_________________

Mail to: COMPTROLLER OF PUBLIC ACCOUNTS

111 E. 17th Street

7. TOTAL TAX DUE (Multiply Item 6 by $5.00) ....................................... $ _________________

Austin, TX 78774-0100

Make this amount payable to the STATE COMPTROLLER.

I am applying for duplicate tax permit(s) for the coin-operated machine(s) listed above which I own. I certify that all information in this application for tax

permit(s) is true and correct to the best of my knowledge and belief.

Type or print name and title of sole owner, partner, officer or authorized representative

Driver’s license number / state

Sole owner, partner, officer or authorized representative

Date

The law provides that a person who knowingly secures or attempts to secure a license by fraud, misrepresentation or subterfuge is guilty of a second degree felony and

upon conviction is punishable by confinement for two (2) to twenty (20) years and a fine up to $10,000. (Occupations Code, §2153.357; Penal Code, §12.33)

Business phone

Residence phone

(Area code and number)

COMPTROLLER USE ONLY

No. of permits issued ________ Occupation Tax Permit(s) issued for Year 20 _____ : Permit number ________________ through _______________

Field office number

E.O. name

User ID

Date

Reference number

If you have any questions about this application, contact your nearest Texas State Comptroller’s office or call us toll free at (800) 252-1385.

The local number in Austin is (512) 463-4600. Our e-mail address is tax.help@cpa.state.tx.us.