Form Bt-144-C - Application To Purchase Coin-Operated Device Decal(S) Page 2
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3STC0008-1092-BT
Oklahoma Tax Commission
State of Oklahoma - Oklahoma Tax Commission
BT-144-C
2501 Lincoln Boulevard
Application to Purchase Coin-Operated Device Decal(s)
Revised 7-2010
Oklahoma City, OK 73194-1000
1
Office Use
Owner’s Name
FEI/SSN
Approved
Disapproved
Mailing Address
Phone Number
Status
City, State, Zip
Coin Device Account Number
Number of Decals
Number and Type of Devices Operated
2
Issued
Type Decal
Full Price
Number of Decals
Amount
A
Type A Decal
$ 150.00
$
B
C
Type B Decal
$ 10.00
$
D
Type C Decal
$ 15.00
$
E
Type D Decal
$
5.00
$
Beginning Number
Type E Decal
$
2.00
$
A
3
Special Decals (for 30 day periods) See Instructions
B
C
Type Decal
Number of Decals Number of Periods
Price
Amount
D
Type A Decal
$ 15.00 per period $
E
Type B Decal
$ 1.00 per period $
Ending Number
Type C Decal
$ 1.50 per period $
A
Type D Decal
$ 0.50 per period $
B
C
$ 0.20 per period $
Type E Decal
D
4
Reason:
(a) Fair, Carnival, etc.
(b) Place of Amusement, Seasonal
E
Location of Devices: Address:
Street Number (Do NOT use P.O. Box or rural route number)
Amount Received
City:
State:
Zip:
Inclusive month(s) for special decals:
/
through
/
Month
Year
Month
Year
Issued By
5
Number of Machines
Penalty
Penalty for Sealed Machine
X $100.00 = $
Received By
6
Total Amount Remitted for Decal Fees and Penalty
7
A decal must be firmly affixed to each coin operated device placed in operation or on
Date Received
location, and must be visible to and readable by the public. All decals expire on June 30.
Date Mailed
Signature/Title (or Sole Owner, Partner, or Corp Officer)
Date of Application
Mandatory inclusion of social security and/or federal identification numbers are required on forms filed with the Oklahoma Tax
Commission pursuant to Title 68 of the Oklahoma Statutes and regulations thereunder, for identification purposes, and are
deemed part of the confidential files and records of the Oklahoma Tax Commission.
The Oklahoma Tax Commission is not required to give actual
Please put your FEI/SSN on your check to
notice to taxpayers of changes in any state tax law.
assure proper credit to your account.
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