Form 69-122 - Vehicle Inventory Supplement For Cigarette, Cigar And Tobacco Products Permit

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69-122

(Rev.7-09/3)

VEHICLE INVENTORY SUPPLEMENT FOR

CIGARETTE, CIGAR AND TOBACCO PRODUCTS PERMIT

• Please type or print.

• Please attach additional sheets, if necessary.

NOTE:

Use this supplement to add additional vehicle inventory for your existing

• Do NOT write in shaded areas.

Cigarette and/or Tobacco Products Permit.

Legal name of owner

Taxpayer number

Vehicle year

Vehicle make

Vehicle model

Comptroller Use Only

License plate number

State

Motor vehicle identification number (VIN)

MISCAPP

Job name -

Microfilm

00991

What is the first in-service date for this vehicle?

1(a) Permit fee due for this vehicle:

1(b) Late fee for this vehicle:

8 8

Reference no.

(Refer to the applicable permit period & fee schedule on the back of this form)

Vehicle year

Vehicle make

Vehicle model

License plate number

State

Motor vehicle identification number (VIN)

What is the first in-service date for this vehicle?

2(a) Permit fee due for this vehicle:

2(b) Late fee for this vehicle:

(Refer to the applicable permit period & fee schedule on the back of this form)

Vehicle year

Vehicle make

Vehicle model

License plate number

State

Motor vehicle identification number (VIN)

What is the first in-service date for this vehicle?

3(a) Permit fee due for this vehicle:

3(b) Late fee for this vehicle:

(Refer to the applicable permit period & fee schedule on the back of this form)

If your place of business is a vehicle, where will business records for the vehicle(s) listed above be maintained? Use street address or directions, city, state and

ZIP Code; NOT P.O. Box, rural route or public storage.) MUST BE A COMMERCIAL LOCATION:

1. Permit fee due for vehicle listed above: .................1(a)

1(b) Late fee (if applicable): ....................................

2. Permit fee due for vehicle listed above: .................2(a)

2(b) Late fee (if applicable): ....................................

3. Permit fee due for vehicle listed above: .................3(a)

3(b) Late fee (if applicable): ....................................

4. Sum of Permit Fees Due

4(b) Sum of late fees due

: ..........

(1(a) plus 2(a) plus 3(a))

.........4(a)

(1(b) plus 2(b) plus 3(b))

5. TOTAL AMOUNT DUE & PAYABLE: (4(a) plus 4(b))

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

Date of application (Mo., day, year)

authorized representative must sign this application. The authorized representative must submit a written

power of attorney with application. (Attach additional sheets, if necessary.)

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, or authorized representative.

Sole owner, partner or officer, or authorized representative.

Type or print name and title of partner or officer, or authorized representative.

Partner or officer, or authorized representative.

Type or print name and title of partner or officer, or authorized representative.

Partner or officer, or authorized representative.

YOUR PERMIT MUST BE PROMINENTLY DISPLAYED IN YOUR VEHICLE.

DISCLOSURE OF INFORMATION PROVIDED ON THIS FORM WILL BE GOVERNED BY THE

TEXAS PUBLIC INFORMATION ACT, GOVERNMENT CODE, CHAPTER 552.

Under Ch. 559, Government Code, you are entitled to review, request and correct information we have on file about you, with limited exceptions in accordance with Ch. 552, Government Code.

To request information for review or to request error correction, contact us at the address or phone numbers listed on this form.

Mail your completed application with the required permit fee to:

Make check payable to:

COMPTROLLER OF PUBLIC ACCOUNTS

STATE COMPTROLLER

111 E. 17th Street

Austin, TX 78774-0100