Form Ap-141 - Texas Application For Additional Coin-Operated Machine Tax Permits Page 2
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2AP-141 (Back)
Texas Application for
(Rev.8-11/14)
Additional Coin-Operated Machine Tax Permits
Page 2
• Type or print.
• Do not write in shaded areas.
Legal name (Same as Item 2)
6. For each additional machine being placed on location and requiring a permit, list the serial number/inventory I.D. number, machine make and machine type.
Note: For registration certificate holders only: If the additional machines requiring permits are being placed in different locations, you MUST complete a separate
application for each location and list the machines placed in that location.
Machine Type
Exhibited
Machine Type
Exhibited
Machine Serial Number /
Machine Make or
Code Used
or
Machine Serial Number /
Machine Make or
Code Used
or
Inventory I.D. Number
Manufacturer
(Use letter codes
Displayed
Inventory I.D. Number
Manufacturer
(Use letter codes
Displayed
from Item 7)
from Item 7)
on Location
on Location
1.
11.
2.
12.
3.
13.
4.
14.
5.
15.
6.
16.
7.
17.
8.
18.
9.
19.
10.
20.
If additional space is needed, add supplemental page. Computer printout may be used.
7. Enter the total number of EACH TYPE of music, skill or pleasure coin-operated machines being placed in ALL locations for which you are purchasing additional tax
permits
– A –
– B –
– C –
– D –
– E –
– F –
Phonographs
Pool Tables
Pinball Games
Video Games
Darts
Other
8. Total number of additional machines in ALL locations that require tax permits. (Total of Item 7A - F) ...............................................................
_________________
Tax rate schedule for each coin-operated machine placed on location for the first time in:
1st quarter (January - March) ........................ $60.00
3rd quarter (July - September) ...................... $30.00
2nd quarter (April - June) .............................. $45.00
4th quarter (October - December) ................. $15.00
9. Calculate the total amount of occupation tax due for permits.
Multiply the number of machines placed on location for the first time in each calendar quarter by the appropriate tax rate for that quarter.
a. 1st quarter: _______________ machines at $60.00 each = $
________________
b. 2nd quarter: _______________ machines at $45.00 each = $
________________
c. 3rd quarter: _______________ machines at $30.00 each = $
________________
d. 4th quarter: _______________ machines at $15.00 each = $
________________
10. Total amount due for tax permits (Total Items 9a, 9b, 9c and 9d) .................................................................................... $ __________________
Note: Payment must be made payable to State Comptroller. Do not send cash.
11. Certification
I am applying for occupation tax permits for the coin-operated machine(s) which are listed in this application. I certify that all information submitted in
this application for tax permit(s) is true and correct.
Type or print name and title of sole owner, partner or officer
Driver license number / state
Sole owner, partner or officer
The law provides that a person who knowingly secures or attempts to secure a license by fraud, misrepresentation or subterfuge is guilty of a second degree felony
and upon conviction is punishable by confinement for two (2) to twenty (20) years and a fine up to $10,000. (Occupations Code §2153.357; Penal Code §12.33)
Business phone
Residence phone
(Area code and number)
(Area code and number)
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.
No. of permits issued ____________
Occupation Tax Permit(s) issued for ___________ :
Permit number _____________ through ___________
Field office number
E.O. name
User ID
Date
Reference number
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