AP-212
(Rev.3-06/2)
COIN-OPERATED MACHINE TAX PERMIT(S)
OWNERSHIP TRANSFER STATEMENT
For Comptroller Use Only
If you transfer ownership of a permitted coin-operated machine for the current calendar year, complete this form.
00990 4420
• TYPE OR PRINT • DO NOT WRITE IN SHADED AREAS
SELLER/PREVIOUS OWNER
Legal name of SELLER / PREVIOUS OWNER (Sole owner, partnership, corporation, or other name) Taxpayer number
Trade name of business Business phone (Area code and number)
Location of business (Street)
City State ZIP code
Legal name of BUYER / NEW OWNER (Sole owner, partnership, corporation, or other name) Taxpayer number
BUYER / NEW OWNER
Trade name of business Business phone (Area code and number)
Location of business (Street)
City State ZIP code
MACHINE TYPE CODES
Machines transferred
A - PHONOGRAPHS B - POOL TABLES C - PINBALL GAMES
(Attach additional sheets, if necessary.) D - VIDEO GAMES E - DARTS F - OTHER
MACHINE SERIAL NUMBER/ MACHINE TYPE CODE
MACHINE MAKE OR MANUFACTURE TAX PERMIT NUMBER
INVENTORY I.D. NUMBER (Use letter codes above.)
1
2
3
4
5
6
MACHINE INVENTORY LIST
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Signature of seller / previous owner Effective date of transfer
If you have any questions, you may contact the Texas State Comptroller’s field office Mail to: COMPTROLLER OF PUBLIC ACCOUNTS
in your area or call 1-800-252-1385, toll free, nationwide. 111 E. 17th Street
The Austin number is 512/463-4600. Austin, TX 78744-0100
You have certain rights under Chapters 552 and 559, Government Code, to review, request, and correct information we have on file about you.
Contact us at the address or toll-free number listed on your application.