Form Ap-133-3 - Texas Application For Fuels Tax Permit - 2015 Page 4
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4AP-133-6
TEXAS APPLICATION FOR
(Rev.12-01/15)
FUELS TAX PERMIT
• TYPE OR PRINT
• Do NOT write in shaded areas.
Page 4
SSN or FEIN
22. Legal name of owner (Same as Item 1 OR Item 5)
If you purchased an existing business or business assets, complete Items 23-26.
Previous owner’s taxpayer number
23. Previous owner’s trade name.
(if available)
24. Previous owner’s legal name, address and phone number, if available.
Phone (Area code and number)
Name
Address (Street and number)
City
State
ZIP code
25. Check each of the following items you purchased.
Inventory
Corporate stock
Equipment
Real estate
Other assets
For Comptroller Use Only
Tax type/reason
2 0
26. Purchase price of this business or assets and the date of purchase.
00991
month
day
year
Reference no.
$
Purchase price
Date of purchase
Items 27 - 34 must be completed by surety company or financial institution. Please make copies of Items 27 - 35 to report multiple bonds.
27. Check type of surety/security securing permit applied for and indicate amount. (Complete only Items indicated.)
Letter of Credit [Assignment Letter of Credit
Certificate of Deposit assignment [Assignment of
$
Cash deposit
(Form 00-812) must be attached]
Certificate of Deposit (Form 00-808) must be attached]
Surety bond (Complete Items 27-35.)
28. Legal name of surety company/financial institution that is authorized and qualified to do business in the State of Texas
29. Mailing address of surety company/financial institution
City
State
ZIP code
County (or country, if outside the U.S.)
30. Surety company/financial institution Federal Employer’s Identification Number
If “YES,” enter number
31. Does surety company/financial institution have a Taxpayer number for
reporting any Texas tax OR a Texas Identification number ........................
YES
NO
32.
Bond beginning effective date
Surety bond number
Bond amount
33. • Applicant as PRINCIPAL and surety company as SURETY, their heirs, executors and assigns, are liable to the State of Texas
for $ ______________________________________ .
• Bond is security for Fuels Tax Permit issued to principal under Fuels Tax Law. (Check only ONE type of permit.)
GASOLINE: (TEX.TAX CODE ANN. sec. 153.116)
DIESEL FUEL: (TEX.TAX CODE ANN. sec. 153.218)
• The bond will be extended from year to year as a new and separate obligation for each year or portion of a year, and it will remain in full force
until the principal pays to the Comptroller of Public Accounts at Austin, Texas, all taxes, penalties, interest and costs due under the permit
applied for.
• Bond will not be invalidated if the Comptroller recovers on the bond, a new bond is issued or if the permit is revoked, renewed or a new permit
issued.
• The Comptroller may demand a new bond if a new permit is issued or an old one renewed.
• The Comptroller may enforce the obligations of this bond, including filing suit, without exhausting remedies against the principal's assets.
Principal does not need to be made a party to any lawsuit.
Surety authorized representative
sign
here
34. Signed this ___________ day of ________________________ , 20 _______
35. The sole owner, all general partners, corporation president, vice-president, secretary or treasurer or an authorized
representative must sign this application. Representative must submit a written power of attorney with application.
(Attach additional sheets, if necessary.)
I (We) declare that the information in this document and any attachments is true and correct to the best of my (our) knowledge and belief.
Type or print name and title of sole owner, partner or officer
Sole owner, partner or officer
sign
here
Type or print name and title of partner or officer
Partner or officer
sign
here
Type or print name and title of partner or officer
Partner or officer
sign
here
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