Form Ap-140 - Texas Application For Duplicate Occupation Tax Permits

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AP-140

(Rev. 9-04/6)

TEXAS APPLICATION

CLEAR FORM

FOR DUPLICATE OCCUPATION TAX PERMITS

• PLEASE READ INSTRUCTIONS

• TYPE OR PRINT

• DO NOT WRITE IN SHADED AREAS

For Comptroller's use only

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

JOB NAME

Registration Certificate

Taxpayer number

AMUSEAPP

General Business License

Master name change

00990

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

4420

XUMAST

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

0 - Send

Mailing address (Street & no., P.O. Box or rural route and box no.)

1 - Do not send

Master mailing

address change

State

City

ZIP code

County

XUMAST

County code

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

Lost

Stolen

Destroyed

Explain briefly how the permit(s) were lost, stolen or destroyed.

_________________________________________________________________________________________

Secondary mailing

address set-up

_________________________________________________________________________________________

XAADDR

THE FEE FOR EACH DUPLICATE TAX 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)

Secondary mailing

address change

MACHINE

LOST, STOLEN OR

MACHINE SERIAL

MACHINE MAKE

XUADDR

TYPE CODE

DESTROYED

NUMBER/INVENTORY

(Use letter code

PERMIT NUMBER

I.D. NUMBER

MANUFACTURER

from below)

Tax type

044

County code

Duplicate permit

PL08

44400

Quarter / Quantity

Payment received

10.

Yes

11.

12.

A - PHONOGRAPH

B - POOL TABLE

C - PINBALL GAME

D - VIDEO GAME

E - DART

F - OTHER

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

6. Total number of duplicate occupation tax permits requested

If you have any questions about this application, contact your nearest

Texas State Comptroller’s Office or call us toll free at 1-800-252-1385.

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

The local number in Austin is 512/463-4600. If you’re calling from a

Make this amount payable to:

STATE COMPTROLLER

Telecommunications Device for the Deaf (TDD), call 1-800-248-4099.

Mail to:

COMPTROLLER OF PUBLIC ACCOUNTS

The Austin TDD number is 512/463-4621. The Tax Help E-mail

111 E. 17th Street

Address is: tax.help@cpa.state.tx.us

Austin, Texas 78774-0100

I am applying for duplicate tax permit(s) for the coin-operated machine(s) listed above. I certify that all information submitted in this application for tax permit(s) is true and correct.

sign

Date

Sole owner, partner or officer

here

Business Phone

Residence Phone

(Area code and number)

(Area Code and Number)

No. of permits issued

Occupation Tax Permit(s) issued for Year 20

: Permit number

through

Field office number

E.O. name/destin

UserID

Date

Reference number

You have certain rights under Ch. 559, Government Code, to review, request, and correct information we have on file about you. Contact us at the address or toll-free number listed on this form.