Texas Form Ap 146 PDF Details

The Texas Original Application for Coin-Operated Machine Registration Certificate and Tax Permit(s), known formally as Form AP-146, lays out the foundational requirements for business owners in Texas who operate or deal with coin-operated machines. This form not only serves as an application for obtaining the necessary registration certificate to legally operate such machines within the state but also outlines the tax responsibilities associated with these machines. Applicants are guided through detailed instructions ensuring that all relevant aspects, from the general instruction to not write in shaded areas to the specific requirement of attaching a computer printout of machine inventory, are meticulously followed. Furthermore, the form encompasses sections that address the addition or removal of machine owners, partners, and corporate stakeholders, emphasizing the necessity of submitting the machine tax permits fee alongside the registration certificate fee. Additionally, it stresses the importance of affixing permits on machines where they are easily visible to the public, complying with payment methods acceptable to the State Comptroller, and adhering to deadlines for the renewal of registration certificates and permits. By encapsulating elements ranging from ownership disclosure to the handling of machines purchased without paying Texas tax, the form acts as a comprehensive guide for current or aspiring coin-operated machine operators in navigating the legal and fiscal landscape specific to Texas.

QuestionAnswer
Form NameTexas Form Ap 146
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesmmddyyyy, 12-month, coin operated amusement machines texas, 1st

Form Preview Example

Texas Original Application for Coin-Operated Machine

Registration Certificate and Tax Permit(s)

Instructions

General Instructions –

Do not write in shaded areas.

Do not separate pages.

Enter actual location address when requested. Do not enter P.O. Box or rural route (Item 13).

The registration certificate fee and the occupation tax due for your machine tax permits must be submitted with this application. Permits must be securely affixed to the machine and in a manner that can be clearly seen by the public. Payment must be made payable to the State Comptroller.

Do not send cash.

Specific Instructions –

Complete the Texas Coin-Operated Machine Ownership Statement, Form AP-138. (To add or delete owners, partners, officers, directors and/or corporate stockholders, a written request must be sent.) Omit all corporate stockholders owning less than 10% of the business.

A computer printout of your machine inventory, or the completed supplement, Form AP-144, Coin-Operated Machine Inventory Supplement For Registration Certificate Holders, may be used instead of completing the inventory list on Page 3. The printout must be numbered and contain all inventory owned at the time your application is submitted.

Each machine listed for the location shown in this application must be registered with the Comptroller by:

a.serial number/inventory I.D. number

b.make or manufacturer

c.type

If you purchase additional machines during the year, you must file the Application For Additional Coin-Operated Machine Tax Permits, Form AP-141.

Each time a machine is moved to a different location, within 10 days of the move, the holder of the Registration Certificate must notify the Comptroller in writing or file the Machine Location Amendment for Registration Certificate Holders, Form AP-142. (Occupations Code §2153.160.)

Current calendar year tax permits can be transferred with the sale of a machine by filing a Coin-Operated Tax Permit(s) Ownership Transfer Statement, Form AP-212.

Registration Certificates and permits expire December 31 of each year, and renewals are due November 30 of each year. If the due date falls on a Saturday, Sunday or legal holiday, the next business day will be the due date.

If you purchase a machine from an out-of-state vendor without paying Texas tax, use tax must be reported. If you paid Texas use tax to a vendor, you are not required to report the tax. That vendor must provide you with a receipt showing, among other things, the amount of use tax collected. You should retain a copy of the receipt showing you paid Texas use tax.

A registration certificate holder may make one or two sales of coin-operated machines during any 12-month period if the certificate holder does not hold out as engaging (or does not habitually engage) in the business of selling machines without losing the licensing exemption. Before the third sale of a coin-operated machine in a 12-month period, a general business or import license must be obtained. See Rule 3.602.

Disclosure of information concerning date of birth and Social Security number is required.

Registration Certificate Fee – $150.00 – Annually

This fee cannot be prorated.

This application must be submitted by any person (sole owner, partnership, corporation or other group) that intends to engage in business to own or operate coin-operated machines exclusively on premises occupied by and in connection with their business.

If you regularly sell machines as a part of your business, you are not qualified to hold a Registration Certificate and you must apply for a General Business License or an Import License, using Form AP-147. Refer to Comptroller Rule 3.602.

A registration certificate cannot be issued to anyone indebted to the State of Texas for any fees, costs or penalties, or to anyone currently delinquent in the payment of any tax collected by the Comptroller.

Completed application and payment should be mailed to: Comptroller of Public Accounts 111 E. 17th St.

Austin, TX 78774-0100

For Assistance – If you have any questions about this application, contact your nearest Texas State Comptroller’s field office or call us at (800) 252-1385 or (512) 463-4600. Our email address is tax.help@cpa.state.tx.us.

Federal Privacy Act – Disclosure of your social security number is required and authorized under law, for the purpose of tax administration and identification 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 file about you. Contact us at the address or phone numbers listed on this form.

AP-146-1 (Rev.8-11/15)

AP-146-2 (Rev.8-11/15)

Below is a listing of taxes and fees collected by the Comptroller of Public Accounts. If you are responsible for reporting or paying one of the listed taxes or fees, and you do not have a permit or an account with us for this purpose, please obtain the proper application by calling (800) 252-5555 or by visiting your local Texas Comptroller field office.

TAX TYPE(S)

9-1-1 Emergency Service Fee/Equalization Surcharge - If you are a telecommunications utility, a mobile service provider or a busi- ness service user that provides local exchange access, equiva- lent local exchange access, wireless telecommunications connec- tions or intrastate long-distance service, and you are responsible for collecting emergency communications charges and/or sur- charges, you must complete Form AP-201.

Automotive Oil Sales Fee - If you manufacture and sell automotive oil in Texas; or you import or cause automotive oil to be imported into Texas for sale, use or consumption; or you sell more than 25,000 gallons of automotive oil annually and you own a warehouse or distri- bution center located in Texas, you must complete Form AP-161.

Battery Sales Fee - If you sell or offer to sell new or used lead acid batteries, you must complete Form AP-160.

Cement Production Tax - If you manufacture or produce cement in Texas, or you import cement into Texas and you distribute or sell cement in intrastate commerce or use the cement in Texas, you must complete Form AP-171.

Cigarette, Cigar and/or Tobacco Products Tax - If you wholesale, distribute, store or make retail sales of cigarettes, cigars and/or tobacco products, you must complete Form AP-175 or Form AP-193.

Coastal Protection Fee - If you transfer crude oil and condensate from or to vessels at a marine terminal located in Texas, you must complete Form AP-159.

Coin-Operated Machine Tax - If you engage in any business deal- ing with coin-operated amusement machines OR engage in busi- ness to own or operate coin-operated amusement machines ex- clusively on premises occupied by and in connection with the busi- ness, you must complete Form AP-146 or Form AP-147.

Crude Oil and Natural Gas Production Taxes - If you produce and/ or purchase crude oil and/or natural gas, you must complete Form AP-134.

Direct Payment Permit - If you annually purchase at least $800,000 worth of taxable items for your own use and not for resale, you must complete Form AP-101 to qualify for the permit.

Fireworks Tax - If you collect tax on the retail sale of fireworks, you must complete Form AP-201. This is in addition to the sales tax permit. You are required to charge both the sales tax and the fireworks tax.

Franchise Tax - If you are a general partnership or a non-Texas entity without a certificate of authority or certificate of registration, you must complete Form AP-114.

Fuels Tax - If you are required to be licensed under Texas Fuels Tax Law for the type and class permit required, you must complete Form AP-133.

Gross Receipts Tax - If you provide certain services on oil and gas wells OR are a utility company located in an incorporated city or town having a population of more than 1,000 according to the most recent federal census and intend to do business in Texas, you must complete Form AP-110.

Off-Road,Heavy-DutyDiesel-PoweredEquipmentSurcharge- If you sell, lease or rent off-road, heavy duty diesel powered equipment, you must complete Form AP-201. This is in addition to the sales tax permit. You are required to charge both the sales tax and the surcharge.

Hotel Occupancy Tax - If you provide sleeping accommodations to the public for a cost of $15 or more per day, you must complete Form AP-102.

International Fuel Tax Agreement (IFTA) - If you operate qualified motor vehicles which require you to be licensed under the International Fuel Tax Agreement, you must com- plete Form AP-178.

Manufactured Housing Sales Tax - If you are a manufacturer of manufactured homes or industrialized housing engaged in business in Texas, you must complete Form AP-118.

Maquiladora Export Permit - If you are a maquiladora enterprise and wish to make tax-free purchases in Texas for export to Mexico, you must complete Form AP-153 to receive the permit.

Motor Vehicle Seller-Financed Sales Tax - If you finance sales of motor vehicles and collect Motor Vehicle Sales Tax in periodic payments, you must complete Form AP-169.

Motor Vehicle Gross Rental Tax - If you rent motor vehicles in Texas, you must complete Form AP-143.

Petroleum Products Delivery Fee - If you are required to be licensed under Texas Water Code, sec. 26.3574, you must complete Form AP-154.

Sales and Use Tax - If you engage in business in Texas, AND you sell or lease tangible personal property or provide taxable services in Texas to customers in Texas, and/or you acquire tangible personal property or taxable services from out-of- state suppliers that do not hold a Texas Sales or Use Tax permit, you must complete Form AP-201.

Sulphur Production Tax - If you own, control, manage, lease or operate a sulphur mine, well or shaft or produce sulphur by any method, system or manner, you must complete Form AP-171.

Telecommunications Infrastructure Fund - If you are a tele- communications utility company or a mobile service provider who collects and pays taxes on telecommunications receipts under Texas Tax Code, Chapter 151, you must complete Form AP-201.

Texas Customs Broker License - If you have been licensed by the United States Customs Service AND want to issue export certifications, you must complete Form AP-168.

AP-146-3

 

Texas Original Application

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Rev.8-11/15)

for Coin-Operated Machine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Registration Certificate and Tax Permit(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• Please read instructions.

• Type or print.

• Do NOT write in shaded areas.

 

 

 

 

 

 

 

 

 

 

 

 

Answer these questions before completing the application.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I. Do you operate or exhibit your machines exclusively in your own place of business which may be owned, leased or rented?

 

 

YES

 

 

 

NO

 

 

 

 

 

If “NO,” stop here. You must apply for a General Business License (Use Form AP-147)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

II. Do you own and operate any “Coin-Operated Machines” located in the place of business of another person?

 

 

 

YES

 

 

 

NO

 

 

 

 

 

III. Do you have any financial interest, direct or indirect, in the coin-operated music, skill or pleasure machine industry?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(For example: manufacture, own, buy, sell, rent, lease, trade, repair, maintain, service, import, transport or exhibit coin-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.............operated machines within the state, other than the machine(s) owned and operated by you in your place of business.)

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you answered “YES” to Items II or III above, stop here. You must apply for a General Business License.

 

 

 

 

 

 

 

 

 

 

(Use Form AP-147)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This application is for calendar year

_______________________

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1. Texas Comptroller’s taxpayer number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

...........................................................................................

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.Legal name of owner (sole owner, partnership, corporation or other name)

3.Mailing address (street number and name, P.O. Box or rural route and box number)

 

 

City

 

 

 

 

 

State

 

 

ZIP code

 

 

 

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Business email address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION

6. Enter your Federal Employer Identification Number (FEIN), if any

...........................................................

 

 

 

 

 

 

 

 

 

...

(

 

 

 

 

 

)

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

4. Enter the daytime phone number of the person primarily responsible for filing tax returns.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TAXPAYER

. ...............................................................5. Enter your Social Security number if you are a sole owner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.....7. If you are incorporating an existing business, enter the taxpayer number of the existing business

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Enter your taxpayer number for reporting any Texas tax OR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

your Texas Vendor Identification Number if you now have or have ever had one

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Indicate how your business is owned.

 

 

 

1 - Sole owner

 

 

 

 

 

 

 

 

 

 

2 - Partnership

 

 

 

 

 

 

3 - Texas corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7 - Limited partnership

 

Foreign corporation

 

 

 

 

 

 

 

 

Other (explain)

___________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Charter, file or COA date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

Texas Secretary of State file number or COA number

month

day

year

 

 

10. If this business is a corporation, enter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home state

Identification number

 

 

 

 

 

 

11. If your business is a limited partnership, enter the home state and identification number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

All applicants

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete the Texas Coin-Operated Machine Ownership Statement, Form AP-138.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION

 

(If business location address is a rural route and box number, provide directions or use 9-1-1 address, if possible.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Trade name of business/machine location

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Business phone (area code and number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

)

 

 

 

 

 

 

-

 

 

 

 

 

 

 

13. Location of business/machine location

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

ZIP code

 

 

 

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AP-146-4

 

Texas Original Application

 

 

 

 

 

(Rev.8-11/15)

for Coin-Operated Machine

 

 

 

 

 

 

 

 

 

 

 

 

 

Registration Certificate and Tax Permit(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

––– Attach additional sheets, if necessary. –––

 

• Please read instructions.

• Type or print.

 

 

 

• Do NOT write in shaded areas.

Page 2

Legal name (same as Item 2)

APPLICANT INFORMATION

14. Check the applicable boxes and complete the information below:

Position

(Check all applicable boxes.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Percentage of ownership or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

corporate

 

 

 

 

 

 

Sole owner

 

 

Partner

 

 

 

 

Director

 

 

Officer

 

Corporate stockholder

 

 

 

 

Record keeper

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

stock held

 

 

 

 

 

 

Name (last, first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security number

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver license number and state

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home address (street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime phone (area code and number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth (mmddyyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position

(Check all applicable boxes.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Percentage of ownership or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

corporate

 

 

 

 

 

 

Partner

 

 

Director

 

 

 

 

 

 

 

 

 

Officer

 

 

Corporate stockholder

 

 

 

Record keeper

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

stock held

 

 

 

 

Name (last, first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security number

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver license number and state

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home address (street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime phone (area code and number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth (mmddyyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position

(Check all applicable boxes.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Percentage of ownership or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

corporate

 

 

 

 

 

 

Partner

 

 

Director

 

 

 

 

 

 

 

 

 

Officer

 

 

Corporate stockholder

 

 

 

Record keeper

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

stock held

 

 

 

 

Name (last, first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security number

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver license number and state

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home address (street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime phone (area code and number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth (mmddyyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position

(Check all applicable boxes.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Percentage of ownership or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

corporate

 

 

 

 

 

 

Partner

 

 

Director

 

 

 

 

 

 

 

 

 

Officer

 

 

Corporate stockholder

 

 

 

Record keeper

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

stock held

 

 

 

 

Name (last, first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security number

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver license number and state

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home address (street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime phone (area code and number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth (mmddyyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position

(Check all applicable boxes.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Percentage of ownership or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

corporate

 

 

 

 

 

 

Partner

 

 

Director

 

 

 

 

 

 

 

 

 

Officer

 

 

Corporate stockholder

 

 

 

Record keeper

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

stock held

 

 

 

 

Name (last, first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security number

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver license number and state

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home address (street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime phone (area code and number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth (mmddyyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position

(Check all applicable boxes.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Percentage of ownership or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

corporate

 

 

 

 

 

 

Partner

 

 

Director

 

 

 

 

 

 

 

 

 

Officer

 

 

Corporate stockholder

 

 

 

Record keeper

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

stock held

 

 

 

 

Name (last, first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security number

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver license number and state

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home address (street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime phone (area code and number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth (mmddyyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

( ) -

AP-146-5

 

Texas Original Application

 

 

 

 

 

(Rev.8-11/15)

for Coin-Operated Machine

 

 

 

 

 

 

 

 

 

 

 

 

 

Registration Certificate and Tax Permit(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

––– Attach additional sheets, if necessary. –––

 

• Please read instructions.

• Type or print.

 

 

 

• Do NOT write in shaded areas.

Page 3

Legal name (same as Item 2)

MACHINE INFORMATION

15.For each machine at this location (Item 13) requiring a permit, list the serial number/inventory I.D. number, machine make and machine type. For each additional location, complete a separate Machine Inventory Supplement for Registration Certificate Holder, Form AP-144, or a computer printout of all numbered inventory may be used. If you use a computer printout, you MUST complete Items 16 and 17.

MACHINE SERIAL

MACHINE MAKE

MACHINE TYPE CODE

NUMBER/INVENTORY

OR

(Use letter codes from Item 16)

I.D. NUMBER

MANUFACTURER

 

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

16. Enter the number of each type of music, skill or pleasure coin-operated machine that you have in all locations.

– A –

– B –

– C –

– D –

– E –

– F –

PHONOGRAPHS

POOL TABLES

PINBALL GAMES

VIDEO GAMES

DARTS

OTHER

 

 

 

 

 

 

....................................................................17. Total number of machines in all locations that require tax permits. (Total of Item 16 A - F)

_______________________

AP-146-6

 

Texas Original Application

 

 

 

 

 

(Rev.8-11/15)

for Coin-Operated Machine

 

 

 

 

 

 

 

 

 

 

 

 

 

Registration Certificate and Tax Permit(s)

 

 

 

 

Page 4

 

 

 

 

 

 

 

 

 

 

• Please read instructions.

• Type or print.

 

 

 

• Do NOT write in shaded areas.

Legal name (same as Item 2)

INFORMATIONPAYMENTOCCUPATION TAX CALCULATION

STATEMENT

When you calculate the occupation tax due on your coin-operated machines, do not include coin-operated cigarette, service, merchandise vending machines, coin-operated amusement machines designed exclusively for children or machines permanently taken out of service.

Occupation Tax Permits

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

18.Calculate the occupation tax due for all machines placed on location during this application year. Multiply the total number of machines placed on location for the first time in the appropriate calendar quarter by the 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 = $

________________

...........................................................................................19. TOTAL OCCUPATION TAX DUE (total Items 18a, b, c and d)

$

_________________

 

 

 

20. Amount due for Registration Certificate Fee

$

150.00

 

 

 

21. Amount due for Occupation Tax Permits (from Item 19)

$

_________________

 

 

 

22. TOTAL AMOUNT DUE (total Item 20 and Item 21)

$

_________________

23. The sole owner, all general partners, corporation or organization president, vice-president, secretary or

Date of signature

 

treasurer, managing director or an authorized representative must sign. A representative must submit a

month

day

year

 

 

 

written power of attorney.

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)

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

Driver license number / state

Type or print name and title of partner or officer

Partner or officer

Driver license number / state

Type or print name and title of partner or officer

Partner or officer

Driver license number / state

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 http://www.Texas.gov. You may also want to contact the municipality and county in which you will conduct business to determine any local governmental requirements.

Field office number

E.O. name

User ID

Date

How to Edit Texas Form Ap 146 Online for Free

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In an effort to complete this PDF form, ensure that you type in the right information in each field:

1. Before anything else, once filling in the AP-147, beging with the part that features the subsequent fields:

AP-138 conclusion process shown (part 1)

2. The next step is usually to fill out these particular fields: Business email address, Enter the daytime phone number of, Enter your Social Security number, Enter your Federal Employer, If you are incorporating an, Enter your taxpayer number for, your Texas Vendor Identification, Indicate how your business is, Sole owner, Partnership, Texas corporation, Limited partnership, Foreign corporation, Other explain, and State.

Stage no. 2 in completing AP-138

3. This third segment is generally quite straightforward, Complete the Texas CoinOperated, All applicants, Trade name of businessmachine, Business phone area code and, Location of businessmachine, If business location address is a, City, State, ZIP code, County, N O T A M R O F N, and N O T A C O L - each one of these form fields needs to be completed here.

Writing part 3 of AP-138

4. This next section requires some additional information. Ensure you complete all the necessary fields - cid Please read instructions, Legal name same as Item, Attach additional sheets if, cid Do NOT write in shaded areas, Page, N O T A M R O F N, Check the applicable boxes and, Position Check all applicable boxes, Sole owner, Partner, Director, Officer, Corporate stockholder, Record keeper, and Percentage of ownership or - to proceed further in your process!

Writing segment 4 of AP-138

Be very mindful when filling out cid Do NOT write in shaded areas and Officer, because this is where a lot of people make mistakes.

5. When you get close to the end of your file, there are a couple extra requirements that must be met. Particularly, N O T A M R O F N, T N A C L P P A, Home address street, City, State, ZIP code, Daytime phone area code and number, Position Check all applicable boxes, Date of birth mmddyyyy, Partner, Director, Officer, Corporate stockholder, Record keeper, and Percentage of ownership or should be filled out.

State, Officer, and Director of AP-138

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