Form As 2914.1 B - Application For Amendments To The Merchant'S Registration Certificate Of A Commercial Location Page 3

Form AS 2914.1 B

Rev. Sep 26 12

Page 3

PART IV - OATH

I hereby declare under penalties of perjury that this application has been examined by me, and that to the best of my knowledge and belief, all the information

provided herein is true, correct and complete. I also agree to notify the Secretary of the Treasury of any change in the information provided on this application,

within 30 days of the change or event. The declaration of the person that prepares this application (except the merchant) is with respect to the available

information, and such information has been verified.

Merchant's name

Merchant's signature

Date

Title

Name of duly authorized agent

Signature of duly authorized agent

Date

Address

Telephone

Social security or employer identification number

TO BE COMPLETED BY THE DEPARTMENT OF THE TREASURY

I certify that today _____________, _____ I have received the following Fiscal Terminal(s) and the following collateral support system(s):

Tx Port Dial-Up

Dial-Up - Hypercom

Dial-Up - Hypercom T4205

Broadband - Hypercom T4220 or

T4210

equivalent

Series:___________________________

Series:_____________________________

Series:__________________________________

Series:______________________________

Amount:__________________________

Amount:____________________________

Amount:_________________________________

Amount:_____________________________

Collateral Support Systems (Parts):

1. Phone Splitter

1. Network Cable

2. Phone Cable (2)

2. Phone Cable

2. Power Supply

2. Phone Cable

3. Power Supply

3. Network Cable

3. SIM Card

3. Power Supply

4. Power Supply

Wireless Hypercom T4230 or

Wireless Hypercom M4230

TX Server

Others

equivalent

Series:___________________________

Series:_____________________________

Series:__________________________________

Series:______________________________

Amount:__________________________

Amount:____________________________

Amount:_________________________________

Amount:_____________________________

Collateral Support Systems (Parts):

1. Power Supply

1. Network Cable

1. _________________________________

2. SIM Card

2. Internal Rechargeable Battery

2. Power Supply

2. _______________________________

3. SIM Card

3.____________________________

According to a visual inspection, the above equipment appears to be in

good or

bad conditions. Description of the Fiscal Terminal(s) in case that they

_____________________________________________________________________________________________

are in bad conditions:

__________________________________________________________________________________________________________

After evaluating this application, I certify that it is complete in all of its parts and that the information provided herein is presumed to be true. Nevertheless, the

Department of the Treasury reserves the right to conduct any future investigation to verify the information and the conditions of the equipment.

Employee's name

Employee's signature

Date

Office and District

Retention: Six (6) years.