Ap 197 Form PDF Details

Form AP 197 is a form used by the Internal Revenue Service to request information from a payer in order to identify the payee of wages or other compensation. The form is also used to request information on the type of compensation, and the date and amount paid. This form is important for employers and tax professionals alike, as it helps ensure that all taxes are properly withheld and reported. As such, it is essential that this form be filled out accurately and completely.

QuestionAnswer
Form NameAp 197 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesform ap 197, texas dyed diesel permit, texas diesel fuel, texas dyed diesel permit search

Form Preview Example

Texas Dyed Diesel Fuel End User

Signed Statement Number Registration

G L E N N H E G A R T E X A S C O M P T RO L L E R O F P U B L I C AC C O U N T S

GENERAL INFORMATION

Who Must Submit This Registration - You must submit this registration if you are a sole owner, partnership, corporation or other

organization; you are located in Texas; and you want to purchase tax-free dyed diesel fuel for off-highway use by issuing a signed statement to your supplier or distributor. You must obtain an End User Number from the Comptroller’s ofice.

For Assistance - If you have any questions regarding this registration, iling tax returns or any other tax-related matter, you may contact the Texas State Comptroller’s ield ofice in your area or call 1-800-252-1383.

You can submit your completed application by mail, fax, or email:

Mail:

Texas Comptroller of Public Accounts

FAX: (512) 936-0012

 

111 E. 17th St.

Email: FuelsTax@cpa.texas.gov

 

Austin, TX 78774-0100

 

We process applications in the order they are received. If you have questions or need more information, contact us at 800-252-1383.

Federal Privacy Act - Disclosure of your Social Security number is required and authorized under law, for the purpose of tax admin- istration and identiication of any individual affected by applicable law. 42 U.S.C. §405(c)(2)(C)(i); Tex. Govt. Code §§403.011 and 403.078. Release of information on this form in response to a public information request will be governed by the Public Information Act, Chapter 552, Government Code, and applicable federal law.

You have certain rights under Chapters 552 and 559, Government Code, to review, request and correct information we have on ile

about you. Contact us at the address or phone numbers listed on this form.

SPECIFIC INSTRUCTIONS

Item 1 - Sole Owner: Enter the irst name, middle initial and last name.

Item 4 - Other Organization: Explain the type of organization. Examples: Social Club, Independent School District, Family Trust.

Item 5 - Partnership: Enter the legal name of the partnership.

Corporation: Enter the legal name exactly as it is registered with the Secretary of State.

Other Organization: Enter the title of the organization.

Items 3 & 6 - If you have both a Texas taxpayer number and a Texas Identiication Number, enter the irst 11 digits of the Texas Iden- tiication Number.

Item 7 - Enter the Federal Employer Identiication Number (FEIN) assigned to your business by the Internal Revenue Service.

Item 9 - Enter the complete mailing address where you wish to receive mail from the Comptroller of Public Accounts. If you wish to receive mail at a different address for other taxes, attach a letter with the other addresses.

Item 13 - Texas Corporation: Enter the ile number assigned by the Secretary of State and date of formation.

Item 14 - Foreign Corporation (chartered out of Texas): Enter the state or country of formation, the charter/ile number and date, and the Texas Secretary of State ile number and date.

Item 16 - Limited Partnership: Enter the state in which the partnership is registered and the limited partnership number issued by the Secretary of State.

Item 17 - Partnership: Enter information for all partners.

If the applicant does not have a Social Security number, enter the Individual Taxpayer Identiication Number (ITIN) or other number assigned by the federal government for use when iling federal income tax returns.

Corporation or Other Organization: Enter information for the principal oficers (president, vice-president, secretary).

Item 19 - Enter the actual location of your business—street address or meaningful directions. Example: “3 miles south of FM 1960

on Jones Road.” Do not use a P.O. Box or Rural Route number.

AP-197-1 (Rev.6-18/14)

AP-197-2

(Rev.6-18/14)

Texas Dyed Diesel Fuel End User

Signed Statement Number Registration

*AP19720W061814*

*AP19720W061814*

* A P 1 9 7 2 0 W 0 6 1 8 1 4 *

• Type or print in ink. • Do not write in shaded areas.

Page 1

 

 

SOLE OWNER IDENTIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Name of sole owner (First, middle initial and last name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Social Security number (SSN)

3. Taxpayer number for reporting any Texas tax OR Texas Identiication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here if you DO NOT

 

 

Number if you now have or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

have a SSN.

 

 

have ever had one.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NON-SOLE OWNER IDENTIFICATION

4. Business organization type

--- ALL SOLE OWNERS SKIP ITEMS 4 - 8 ---

Texas registered limited liability partnership (PX)

Non-Texas registered limited liability partnership (PY)

General partnership (PB, PI) Limited partnership (PL or PF)

Other (explain)

 

Texas limited liability company (CL)

 

Non-Texas limited liability company (CI)

 

Texas proit corporation (CT)

 

Non-Texas proit corporation (CF)

 

 

 

Texas nonproit corporation (CN)

 

Non-Texas nonproit corporation (CM)

 

 

Trust (FM or TR) (Please submit a copy of the trust agreement with this application.)

Estate (ES)

Professional corporation (CP) Professional association (AP)

5.Legal name of partnership, company, corporation, association, trust or other (Do not list DBA.)

6.Taxpayer number for reporting any Texas tax or Texas Identiication Number if you now have or have ever had one

7.Federal Employer Identiication Number (FEIN) assigned by the Internal Revenue Service ...............................................

8. Check here if you do not have a FEIN . ......................................................................................................................... ....

BUSINESS INFORMATION

TAXPAYER INFORMATION

9.

Mailing address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street number, P.O. Box or rural route and box number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/province

 

 

 

 

 

 

 

 

 

 

 

 

ZIP code

 

 

 

County (or country, if outside the U.S.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

 

Name of person to contact regarding day to day business operations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

 

Principal type of business

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agriculture

 

 

 

 

Transportation

 

 

 

Retail Trade

 

 

Real Estate

 

 

 

 

 

Mining

 

 

 

 

Communications

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Finance

 

 

 

 

Services

 

 

 

Construction

 

 

Utilities

 

 

 

 

 

Insurance

 

 

 

 

Public Administration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manufacturing

 

 

 

 

Wholesale Trade

 

 

 

Other (explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

 

Primary business activities and type of products or services to be sold

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you are a SOLE OWNER, skip Items 13 - 17.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. If the business is a Texas proit entity, nonproit entity, professional entity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

File number

 

 

 

 

 

 

 

 

 

 

Month Day

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or limited liability company, enter the ile number and date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. If the business is a non-Texas proit entity, nonproit entity, professional entity or limited liability company, enter the state or country of formation, charter/ile number and date, Texas Secretary of State ile number and date.

State/country of formation Charter/ile numberMonth Day YearTexas Secretary of State ile number Month Day Year

15.

.......If the business is a entity, have you been involved in a merger within the last seven years?

 

YES

 

 

NO

(If “YES,” attach a detailed explanation.)

16.

If the business is a limited partnership or registered limited liability

 

 

 

 

State

 

Number

 

 

 

 

 

 

 

 

 

 

partnership, enter the home state and registered identiication number

 

 

 

 

 

 

 

 

17.General partners, principal members/oficers, managing directors or managers (ALL GENERAL PARTNERS MUST BE LISTED - Attach additional sheets, if necessary.)

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

Phone (Area code and number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

 

 

 

 

 

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN or ITIN

 

 

 

 

 

 

Percent of

 

 

 

 

 

 

 

 

 

Driver license number

 

State

 

County (or country, if outside the U.S.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ownership

________

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position held

 

 

Partner

 

 

 

Oficer

 

Director

 

 

 

 

Corporate stockholder

 

Record keeper

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

Phone (Area code and number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

 

 

 

 

 

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN or ITIN

 

 

 

 

 

 

Percent of

 

 

 

 

 

 

 

 

 

Driver license number

 

State

 

County (or country, if outside the U.S.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ownership

________

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position held

 

 

 

Partner

 

 

 

Oficer

 

 

Director

 

 

 

 

Corporate stockholder

 

 

Record keeper

 

 

 

 

 

 

 

 

 

 

 

 

 

AP-197-3

(Rev.6-18/14)

Texas Dyed Diesel Fuel End User

Signed Statement Number Registration

*AP19730W061814*

*AP19730W061814*

* A P 1 9 7 3 0 W 0 6 1 8 1 4 *

• Type or print in ink. • Do not write in shaded areas.

Page 2

 

18.Legal name of entity (Same as Item 1 OR Item 5)

LOCATION

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

BUSINESS

 

 

 

 

 

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.)

 

 

 

 

 

SSN or FEIN

State

 

ZIP code

 

County

 

 

 

 

 

 

 

 

 

 

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

AG

•

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 artiicial 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, ishing for rods or tubing, repair tubing leak, change packer or anchor, hot oil or water treatment of casing, tubing or low lines, marketers, speculators or transportation com- panies. (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 End User Signed Statement Number for agricultural users authorizes the tax-free purchase of only dyed diesel fuel for exclusive use in agricultural 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 deined 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. (EXCEPTION: An agricultural purchaser that uses an End User Signed Statement Number is authorized to purchase up to 25,000 gallons per month.)

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 deined 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

 

 

 

 

 

 

 

SIGNATURES

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.

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 ines 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

(our) knowledge and belief.

 

 

 

 

Month Day

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type or print name and title of sole owner, partner or oficer

 

 

 

Sole owner, partner or oficer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type or print name and title of partner or oficer

 

 

 

Partner or oficer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type or print name and title of partner or oficer

 

 

 

Partner or oficer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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4. You're ready to fill in this fourth form section! In this case you will have these Legal name of entity Same as Item, SSN or FEIN, Business location name and address, Street and number Do not use PO, City, State, ZIP code, County, Physical location of your business, Business location phone, N O T A C O L S S E N S U B, Fuel use type Check only one, DD An End User Signed Statement, Will the dyed diesel fuel be used, and YES fields to do.

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5. Now, the following final portion is precisely what you will need to complete prior to finalizing the form. The blanks in question are the next: AG An End User Signed Statement, offhighway equipment operated in, How many dieselpowered onroad, Bulk storage is deined as a, YES, YES, The sole owner all general, authorized representative must, I We declare that all of the dyed, vehicles operating on the public, I will not make purchases in, S E R U T A N G S, If any of the statements above are, I am aware that certain ines and, and I We further declare that the.

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