Form Ap-170-2 - Texas Application For Prepaid Fuels Tax Permit/decal (Page 2 of 2) in pdf

Form Ap-170-2 - Texas Application For Prepaid Fuels Tax Permit/decal Page 2

AP-170-3

(Rev.4-00/3)

TEXAS APPLICATION FOR PREPAID

FUELS TAX PERMIT / DECAL

Page 2.

Please read instructions

• TYPE OR PRINT

• Do not write in shaded areas

13. Legal name of owner (Sole owner, partnership, corporation or other name)

14. Check the specific type of permit/decal you are applying for:

Diesel Fuel (Form 06-216 and payment must be attached.)

Diesel fuel tax prepaid user (Agricultural use ONLY)

Prepaid Decal (Form 06-215 and payment must be attached.)

Tax decal for compressed natural gas (CNG)

Tax decal for propane (LPG)

Tax decal for liquefied natural gas (LNG)

Tax decal for motor vehicle dealers (Texas dealer number) ______________________________

15. Enter the date the prepaid diesel or the liquefied gas system vehicle was placed in operation

The sole owner, all general partners, corporation president, vice-president, secretary, treasurer or an

Date of application

authorized representative must sign this application. Representative must submit a written power of

(Month, day, year)

attorney with application.

(Attach additional sheets if necessary.)

16. 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

sign

here

Type or print name and title of partner or officer

Partner or officer

sign

here

Type or print name and title of partner or officer

Partner or officer

sign

here

Field office number

E.O. name

ACID

Date

Form Ap-170-2 - Texas Application For Prepaid Fuels Tax Permit/decal Page 2