Form Ap-133-3 - Texas Application For Fuels Tax Permit - 2015 Page 2

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AP-133-4

TEXAS APPLICATION FOR

(Rev.12-01/15)

FUELS TAX PERMIT

• TYPE OR PRINT

Page 2

• Do NOT write in shaded areas.

18. Legal name of entity (Same as Item 1 OR Item 5)

SSN or FEIN

19. Business location name and address (Attach additional sheets for each additional location.)

Business location name

Street and number (Do not use P.O. Box or rural route)

City

State

ZIP code

County

Physical location (If business location address is a rural route and box number, provide directions.)

Business location phone

PERMIT TYPES

YOU MAY APPLY FOR MULTIPLE PERMITS ON THIS APPLICATION.

20. Please check the type of permit(s) for which you are applying.

A - DISTRIBUTOR - Any person who regularly makes sales or distributions of gasoline which are not deliveries into the fuel supply tanks of motor vehicles,

motorboats or aircraft; or who refines, distills, manufactures, produces or blends for sale or distribution gasoline in this state; imports or exports gasoline

other than in the fuel supply tanks of motor vehicles; or in any other manner acquires or possesses tax-free gasoline. If you transport motor fuel for

others in this state as a common or contract carrier, you must also complete Form AP-198.

1. Will all sales and purchases be tax-paid once permitted? (If “YES,” see Jobber Permit) ..............................................................

YES

2. Do you export or import fuel checked other than in the fuel supply tanks of motor vehicles? .......................................................

YES

3. Do you refine, distill, manufacture, produce or blend fuel for sale or distribution? ........................................................................

YES

4. Do your regularly make deliveries of gasoline into storage facilities maintained by others? .........................................................

YES

5. Over the next year, state the average total tax-free gallons acquired per month ..........................................................................

_________________

.40

6. REQUIRED BOND AMOUNT (Multiply amount in Item 5 by .40 to calculate the required bond amount)

(Report this amount in Item 27 of this application. Minimum = $30,000; maximum = $600,000.) ...............................................

_________________

B - JOBBER - Any person who buys tax-paid gasoline or diesel fuel from a permitted distributor or supplier, another jobber, or dealer and makes a sale with

the tax included to a permitted distributor, supplier, another jobber, dealer or bulk user. A permitted jobber may only purchase tax-paid fuel and make

sales with the tax included.

1. Please check the appropriate fuel type .........................................................................................................................

Diesel Fuel

Gasoline

2. Will ALL sales and purchases be tax paid? ...................................................................................................................................

YES

If “NO,” you do not qualify for this permit type. (See Distributor/Supplier)

NOTE: A bond may be required and shall be determined by the Comptroller.

C - INTERSTATE TRUCKER - Any person who operates a motor vehicle only in Mexico and the state of Texas for commercial purposes and the motor

vehicle (1) has two axles with a registered gross weight in excess of 26,000 pounds; (2) has three axles; or (3) is used in combination and the registered

gross weight of the combination exceeds 26,000 pounds. If you are base plated in Texas and travel to other states, you may need to apply for an

International Fuel Tax Agreement license (Form AP-178) or a trip permit. If you are base plated in another IFTA state or Canadian province, check with

that jurisdiction’s officials.

1. Please check the appropriate fuel type .......................................................................................

Liquefied Gas

Diesel Fuel

Gasoline

NOTE: If you purchase liquefied gas in bulk to be used in a motor vehicle that is licensed as an Interstate

Trucker or registered under IFTA, you must also apply for a Liquefied Gas Tax Dealer Permit.

2. Do you travel in Texas and Mexico only? .......................................................................................................................................

YES

3. Do you maintain bulk storage facilities in Texas? ...........................................................................................................................

YES

D - AVIATION FUEL DEALER - Any person who is the operator of an aircraft servicing facility delivering gasoline, AV-gas, diesel, or Jet A fuel exclusively

into the fuel supply tanks of aircraft or into equipment used solely for servicing aircraft and used exclusively off-highway. An aviation fuel dealer cannot

distribute any gasoline or diesel fuel on which a fuels tax is required to be collected or paid to this state.

1. Please check the appropriate fuel type ........................................................................................................................

Diesel Fuel

Gasoline

2. Do you operate an aircraft servicing facility (fixed based operation)? ...........................................................................................

YES

3. Do you export/import fuel other than in fuel supply tanks? ...........................................................................................................

YES

If “YES,” you do not qualify for this permit type. (See Distributor or Supplier)

4. Do you buy aviation fuel for your own use? ...................................................................................................................................

YES

5. Do you sell aviation fuel to others? ................................................................................................................................................

YES