Form Ap-14 - Machine Location Amendment For Registration Certificate Holders
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1AP-142
PRINT FORM
CLEAR FIELDS
(Rev.5-13/8)
Machine Location Amendment for Registration Certificate Holders
For Comptroller Use Only
• The Coin-Operated Machines Law (Occupations Code 2153.158) requires that the holder of a
Registration Certificate shall indicate the name and location address of each machine and certify
00990
4420
that a valid tax permit is affixed to each machine.
• If you move any machine during the year, you are required to complete this amendment form and
return it to the Comptroller’s office within 10 days of the move. (Occupations Code 2153.160)
• NOTE: You must complete a separate form for each location to which you moved machines and list the machines moved to that location.
• Type or print.
• Do not write in shaded areas.
1. Legal name of owner
Taxpayer number
(Sole owner, partnership, corporation, or other name)
2. Mailing address
(Street and nunber, P.O. Box or Rural Route and box number)
City
State
ZIP code
County
3. Trade name of your business where machine(s) has been relocated
Phone
(Area code and number)
4. Location of this business
(Use street and number or directions. P.O. Box or Rural Route NOT acceptable)
City
State
ZIP code
County
5. For each machine moved to this location, list the date moved, serial number / inventory I.D. number, make, type, and check if the machine has
or does not have a valid tax permit affixed.
VALID
DATE THE
MACHINE
MACHINE
TAX PERMIT
MACHINE WAS
SERIAL NUMBER /
MACHINE MAKE OR MANUFACTURE
TYPE CODE
AFFIXED?
MOVED
INVENTORY I.D. NUMBER
(Use letter code from below.)
1.
YES
NO
2.
YES
NO
3.
YES
NO
4.
YES
NO
5.
YES
NO
6.
YES
NO
7.
YES
NO
8.
YES
NO
9.
YES
NO
10.
YES
NO
11.
YES
NO
12.
YES
NO
13.
YES
NO
14.
YES
NO
15.
YES
NO
A
B
C
D
E
F
- PHONOGRAPHS
- POOL TABLES
- PINBALL GAMES
- VIDEO GAMES
- DARTS
- OTHER
If additional space is needed, add supplemental pages.
I certify that all information in this amendment is true and correct.
Sole owner, partner, or officer
Date
Mail to: Texas Comptroller of Public Accounts
111 E. 17th Street
For assistance - If you have any questions about this application,
Austin, TX 78774-0100
contact your nearest Texas Comptroller’s office or call 1-800-252-1385 or
You have certain rights under Chapters 552 and 559, Government Code, to
512-463-4600.
review, request and correct information we have on file about you. Contact us
at the address or phone number listed on this form.
Field office number
E.O. name
User ID
Date
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