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

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AP-133-5

TEXAS APPLICATION FOR

(Rev.12-01/15)

FUELS TAX PERMIT

• TYPE OR PRINT

Page 3

• Do NOT write in shaded areas.

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

SSN or FEIN

E - SUPPLIER - Any person who refines, distills, manufactures, produces, blends for sale or distribution clear diesel or dyed diesel in this state, or imports

or exports clear diesel or dyed diesel other than in the fuel supply tanks of motor vehicles, or sells or delivers clear diesel or dyed diesel in bulk quantities

to dealers, users, aviation fuel dealers, other suppliers or to consumers for non-highway use. If you transport motor fuel for others in this state as a

common or contract carrier, you must 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 diesel fuel other than in the fuel supply tanks of motor vehicles? ...........................................................

YES

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

YES

4. Do you regularly make deliveries of diesel fuel into storage facilities maintained by others? ........................................................

YES

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

_________________

.40

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

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

_________________

F - DYED DIESEL FUEL BONDED USER - A nonagricultural user whose purchases of dyed diesel fuel are for non-highway use, except as provided by Sec.

153.230, Tax Code, and authorized to purchase ONLY dyed diesel fuel tax free from permitted suppliers. A dyed diesel fuel Bonded User Permit

authorizes a user to purchase more than 10,000 gallons a month of dyed diesel fuel for the user’s own use.

1. Is your business activity other than agriculture? ............................................................................................................................

YES

2. Do you intend to purchase more than 10,000 gallons a month of dyed diesel fuel? .....................................................................

YES

3. Will you purchase 3,000 gallons or less per delivery and 10,000 gallons or less per month? ......................................................

YES

If “YES,” you may qualify to issue a Signed Statement.

4. Do you have bulk storage facilities? ..............................................................................................................................................

YES

5. Are you purchasing the dyed diesel fuel exclusively for your own use? ........................................................................................

YES

6. Will any of the dyed diesel fuel be delivered into the fuel supply tank of a motor vehicle licensed for highway use? ...................

YES

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

_________________

.40

8. REQUIRED BOND AMOUNT (Multiply amount in Item 7 by .40 to calculate the required bond amount)

(Report this amount in Item 27 of this application. Minimum = $10,000; maximum = $600,000.) ...............................................

_________________

G - AGRICULTURAL BONDED USER - A user whose purchases of dyed and undyed (clear) diesel fuel will be used exclusively for off-highway agricultural

purposes, and authorized to purchase dyed and undyed diesel fuel tax free from permitted suppliers. An agricultural bonded user diesel fuel permit

authorizes a user to purchase more than 10,000 gallons a month of dyed and undyed diesel fuel for the user’s own use.

1. Do you own or operate a business that is directly engaged in the production of crops, livestock, and/or

other agricultural products that are held for sale in the regular course of business? ....................................................................

YES

2. Do you intend to purchase more than 10,000 gallons a month of dyed and undyed diesel fuel? .................................................

YES

3. Will you purchase 3,000 gallons or less per delivery and 10,000 gallons or less per month? ......................................................

YES

If “YES,” you may qualify to issue a Signed Statement.

4. Do you have bulk storage facilities? ..............................................................................................................................................

YES

5. Are you purchasing the dyed and undyed diesel fuel exclusively for your own use? ....................................................................

YES

6. Will any of the dyed and undyed diesel fuel be delivered into the fuel supply tank of a motor vehicle? ........................................

YES

7. Over the next year, state the average total tax-free gallons acquired per month, for each fuel type .............................................

_________________

.40

8. REQUIRED BOND AMOUNT (Multiply amount in Item 7 by .40 to calculate the required bond amount)

(Report this amount in Item 27 of this application. Minimum = $10,000; maximum = $600,000.) ...............................................

_________________

H - LIQUEFIED GAS DEALER - A dealer authorized to collect and pay taxes on liquefied gas delivered into the fuel supply tanks of motor vehicles

displaying an out-of-state license plate or a current year IFTA decal and/or vehicles displaying motor vehicle dealers liquefied gas tax decal.