Form Ap-197-3 - Texas Dyed Diesel Fuel End User Signed Statement Number Registration Page 4
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4*AP19740W051513*
AP-197-4
(Rev.5-15/13)
*AP19740W051513*
Texas Dyed Diesel Fuel End User
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Signed Statement Number Registration
Page 2
• Type or print in ink.
• 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 of your business in Texas or physical location where performing a contract in Texas
(If business location address is a rural route and box number, provide directions.)
Business location phone
20. Fuel use type (Check only one.)
DD
An End User Signed Statement Number authorizes the tax-free purchase of only dyed diesel fuel for use in off-highway equipment operated in
•
Texas for non-agricultural purposes. Non-agricultural purposes include diesel fuel used by construction companies (road, commercial buildings
or residential), manufacturers (forklifts, loaders, welding machines, space heaters or generators), commercial trucking companies or excavating
companies (land clearing or mowing services). Non-agricultural also consists of agricultural cooperatives, associations, cotton gins, farm supply
stores, tractor supply stores, feed stores or veterinary services.
Will the dyed diesel fuel be used in oil and gas production? ..........................................................................................................
YES
NO
The dyed diesel fuel is consumed to start initial production or increase production on the formation. Oil and gas production consists of fracturing
(frac job), perforating, squeeze cement, workover, acidizing, logging, drilling deeper, plug back, completion, plug and abandon, pulling or resetting
casing liner, installing a casing liner, drilling out a plug, putting on artificial lift (new installation), running a bottom hole bomb, swabbing, jetting,
gravel packing and hot oil treatment of formation. Oil and gas production does not consist of companies that perform maintenance (set units,
mow around unit and tank batteries, paint unit and tank batteries, and gauge tanks), pump changes, rod or tubing jobs, fishing for rods or tubing,
repair tubing leak, change packer or anchor, hot oil or water treatment of casing, tubing or flow lines, marketers, speculators or transportation
companies.
AG
An End User Signed Statement Number for agricultural users authorizes the tax-free purchase of only dyed diesel fuel for exclusive use in agricultural
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off-highway equipment operated in Texas, such as a tractor or combine, on a farm or ranch. A farm or ranch is one or more tracts of land used,
either in whole or in part, in the production of crops, livestock and/or other agricultural products held for sale in the regular course of business.
A feed lot, livestock auction facility, dairy farm, poultry farm, commercial orchard, commercial nursery, timber operation or similar commercial
agricultural operation is a farm or ranch. Timber operations include the production of timber including land preparation, planting, maintenance and
gathering of trees commonly grown for commercial timber. Wildlife management is agricultural use as defined by the Texas Tax Code, 23.51(7).
A home garden is not a farm or ranch. An agricultural non-highway purpose does not include the processing, packaging or marketing of agricul-
tural products by anyone other than the original producer.
21. How many diesel-powered on-road motor vehicles do you own? ..............................................................................................
22. Do you maintain bulk storage in Texas? ...................................................................................................................................................
YES
NO
[Bulk storage is defined as a container of more than 10 gallons. (Tex. Tax Code Ann. Sec. 162.001)]
23. Will all dyed diesel fuel be used in off-highway equipment in Texas? ........................................................................................................
YES
NO
24. The sole owner, all general partners, corporation or organization president, vice-president, secretary or treasurer, managing director or an
authorized representative must sign. A representative must submit a written power of attorney. (Attach additional sheets, if necessary.)
I (We) declare that:
(1) all of the dyed diesel fuel purchased on a signed statement will be consumed by the purchaser and will not be resold;
(2) none of the dyed diesel fuel purchased on a signed statement will be delivered or permitted to be delivered into the fuel supply tanks of motor
vehicles operating on the public highways in this state; and
(3) I will not make purchases in excess of 10,000 gallons per month. (EXCEPTION: A purchaser that uses an End User Signed Statement Number
to purchase dyed diesel fuel for its exclusive use in oil or gas production must also furnish a Letter of Exception issued by the Comptroller that
authorizes the purchase of up to 25,000 gallons per month. An agricultural purchaser that uses an End User Signed Statement Number is
authorized to purchase up to 25,000 gallons per month.)
If any of the statements above are not true, you do not qualify to buy dyed diesel fuel in Texas on a Signed Statement. You may apply for a Dyed
Diesel Fuel Bonded User License.
I am aware that certain fines and criminal penalties are provided by law for providing false information in obtaining a dyed diesel fuel End User
Signed Statement Number.
I (We) further declare that the information in this document and any attachments is true and correct to the best of my
Month
Day
Year
(our) knowledge and belief.
Type or print name and title of sole owner, partner or officer
Sole owner, partner or officer
Type or print name and title of partner or officer
Partner or officer
Type or print name and title of partner or officer
Partner or officer
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