This document is a Texas application form for duplicate coin-operated machine tax permits. It requests information such as the applicant's registration certificate or general business license number, contact information, details of the lost, stolen or destroyed permits being replaced, and a total number of duplicate permits requested. The applicant must certify the accuracy of the information and pay a $5 fee for each duplicate permit issued.

1. AP-140
PRINT FORM RESET FORM
(Rev.11-07/8)
TEXAS APPLICATION FOR You have certain rights under Chapters 552 and 559, Government Code,
to review, request and correct information we have on file about you.
DUPLICATE COIN-OPERATED MACHINE TAX PERMIT(S) Contact us at the address or toll-free number listed on this form.
1. I hold one of the following: (Check one) Texas taxpayer number
REGISTRATION CERTIFICATE GENERAL BUSINESS LICENSE
2. Legal name of machine owner (Sole owner, partnership, corporation or other name)
3. Check here if there has been a change in your mailing address. Enter the correct address.
Machine owner’s mailing address
Street name and number, P.O. Box or Rural Route and box number
City State ZIP code County
4. Were the tax permit(s) lost, stolen or destroyed? (Check the appropriate box.) ............................... LOST STOLEN DESTROYED
Explain briefly how permit(s) were lost or destroyed. ___________________________________________________________________________
____________________________________________________________________________________________________________________
THE FEE FOR EACH DUPLICATE PERMIT IS $5.00.
5 List the number of each tax permit to be replaced. (Include serial number/inventory number, machine make and machine type.)
LOST, STOLEN OR MACHINE SERIAL
DESTROYED NUMBER / INVENTORY MACHINE MAKE OR MANUFACTURER MACHINE TYPE CODE
(Use letter code from below)
PERMIT NUMBER I.D. NUMBER
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
A - PHONOGRAPH B - POOL TABLE C - PINBALL GAME D - VIDEO GAME E - DART F - OTHER
If additional space is needed, add supplemental page. COMPUTER PRINTOUT MAY BE USED.
6. Total number of duplicate occupation tax permits requested.. ........... _________________
Mail to: COMPTROLLER OF PUBLIC ACCOUNTS
111 E. 17th Street
7. TOTAL TAX DUE (Multiply Item 6 by $5.00) ....................................... $ _________________
Austin, TX 78774-0100
Make this amount payable to the STATE COMPTROLLER.
I am applying for duplicate tax permit(s) for the coin-operated machine(s) listed above which I own. I certify that all information in this application for tax
permit(s) is true and correct to the best of my knowledge and belief.
Type or print name and title of sole owner, partner, officer or authorized representative Driver’s license number / state
Sole owner, partner, officer or authorized representative Date
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)
Business phone Residence phone
(Area code and number) (Area code and number)
COMPTROLLER USE ONLY
No. of permits issued ________ Occupation Tax Permit(s) issued for Year 20 _____ : Permit number ________________ through _______________
Field office number E.O. name User ID Date Reference number
If you have any questions about this application, contact your nearest Texas State Comptroller’s office or call us toll free at (800) 252-1385.
The local number in Austin is (512) 463-4600. Our e-mail address is tax.help@cpa.state.tx.us.