Form Ap-146-3 - Texas Original Application For Coin-Operated Machine Registration Certificate And Tax Permit(S) Page 6

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Texas Original Application

AP-146-6

(Rev.8-11/15)

for Coin-Operated Machine

Registration Certificate and Tax Permit(s)

• Please read instructions.

• Type or print.

• Do NOT write in shaded areas.

Page 4

Legal name (same as Item 2)

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) ........................................................................................... $ _________________

150.00

20. Amount due for Registration Certificate Fee ...................................................................................................................... $ _________________

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

month

day

year

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

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