Form Ap-171 - Texas Tax Questionnaire Page 3
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3AP-171-3
TEXAS TAX QUESTIONNAIRE
(Rev.1-07/5)
Page 2.
• PLEASE READ INSTRUCTIONS
• TYPE OR PRINT
• DO NOT WRITE IN SHADED AREAS
14. Legal name of owner (Same as Item 1)
For Comptroller's use only
If you purchased an existing business or business assets, complete Items 15 - 18. If you did not, skip to Item 19.
15. Enter the former owner's trade name. If known, enter the former owner's Texas taxpayer number.
OF
NR
Trade name of former owner
Taxpayer number of former owner
Former owner is
16. Enter the former owner's legal name. If known, enter the former owner's address and telephone number.
Legal name of former owner
Phone (Area code & number)
Active
OOB
Address of former owner (Street & number, city, state, ZIP Code)
17. Check each of the following items you purchased. (This includes the value of stock exchanged for assets.)
Inventory
Corporate stock
Equipment
Real estate
Other assets
18. Enter the purchase price of the business or assets purchased and the date of purchase.
Date of purchase
Purchase price
The sole owner, all general partners, corporation president, vice-president, secretary or treasurer or an
Date of application
authorized representative must sign this application. Representative must submit a power of attorney with
the application. (Attach additional sheets if necessary.)
19. I (We) declare that the information in this document and any attachments is true and correct to the best of my (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
Field office number
E.O. name
Destin
Date
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