Form Ap-101-2 - Application For Direct Payment Permit Form - 2017 Page 2
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1
2Texas Application
AP-101-3
(Rev.1-15/17)
Page 2
for Direct Payment Permit
• Please read instructions.
• Type or print.
• Do not write in shaded areas.
12. Legal name of owner (same as Item 2)
13. List all general partners, officers or managing members of your business. (Attach additional sheets, if necessary.)
If you are sole owner, skip Item 13.
Name
Phone (Area code and number)
Home address
City
State
ZIP code
SSN
FEIN
County (or country, if outside the U.S.)
Percent of
%
ownership
Position held:
General partner
Officer/Director
Managing member
Other
Name
Phone (Area code and number)
Home address
City
State
ZIP code
SSN
FEIN
County (or country, if outside the U.S.)
Percent of
%
ownership
Position held:
General partner
Officer/Director
Managing member
Other
14. Business name
Business phone (Area code and number)
15. Location of your principal place of business (Use street and number or directions - NOT P.O. Box or rural route number.)
City
State
ZIP code
County
16. Is your business located inside the city limits of the city named in Item 15? ..................................................................
YES
NO
17. Indicate your principal type of business.
Exploration/Production
Construction
Manufacturer/Processor
Service
Other
18. Describe your Texas business and the goods or services you sell. (See instructions.)
$
19. Enter the amount of your annual purchases subject to Texas Use Tax .....................................
20. On a separate sheet, describe the accounting method that you will use to differentiate between taxable purchases, exempt purchases,
tax-paid purchases and items purchased tax free for resale. (See instructions.)
21. List and describe all sites of major fixed assets permanently located within Texas. (Attach additional sheets, if necessary.)
The sole owner, all general partners, members, officers or an authorized representative
Month
Day
Year
must sign this application. Representative must submit a written power of attorney
with this application. (Attach additional sheets, if necessary.)
Date of signature
22. I (We) declare, under penalties prescribed by law, that the information in this document and any attachments is true and correct to the best
of my (our) knowledge and belief.
Legal cite: Tex. Penal Code Ann. Sec. 37.10
Type or print name of sole owner, partner or officer
Sole owner, partner or officer
Type or print name of partner or officer
Partner or officer
Type or print name of partner or officer
Partner or officer
WARNING. You may be required to obtain an additional permit or license from the State of Texas or from a local governmental entity to
conduct business. A listing of links relating to acquiring licenses, permits, and registrations from the State of Texas is available online
at You may also want to contact the municipality and county in which you will conduct business to determine
any local governmental requirements.
Field office or section number
Employee Name
USERID
Date
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