ESBD_529530_1781907796532_Attachment C - AP 152 Form.pdf

SIC Security Zone code

4. Name of payee (Individual or business to be paid)

5. Mailing address where you want to receive payments

6. (Optional)

7. (Optional)

8. (Optional)

9. City State ZIP code

10.

Se ct io n

Payee telephone number (Area code and number) type code ( 0, 1, 2 ) code

Payee Information (Please type or print)

2. Texas Identification Number (TIN) - Indicate the type of number you are providing to be used for your TIN Employer Identification Number (EIN) (9 digits)

Se ct io n

1 Social Security number (SSN) (9 digits)

Individual Taxpayer Identification Number (ITIN) (9 digits)

Comptroller's assigned number (FOR STATE AGENCY USE ONLY) (11 digits)

Current Texas Identification Number (FOR STATE AGENCY USE ONLY) (11 digits)

3. Are you currently reporting any Texas tax to the Comptroller's office such as sales tax or franchise tax? YES NO

Enter the number indicated

If "YES," enter Texas Taxpayer Number

1. Is this a new account? YES Mail Code 000 NO Enter Mail Code Agency number Complete Sections 1 - 5 Complete Sections 1, 2 & 5

For Comptroller's use only

11. Ownership Codes - Check only one code by the appropriate ownership type that applies to you or your business.

L - Texas Limited Partnership:

If checked, enter the Texas File Number

T - Texas Corporation:

If checked, enter the

Owner's name Texas File Number

SSN / ITIN (9 digits) A - Professional Association:

If checked, enter the

Se ct io n

3 Texas File Number

C - Professional Corporation:

If checked, enter the Texas File Number

I - Individual Recipient (not owning a business)

S - Sole Ownership (Individual owning a business): If checked, enter the owner's name and Social Security number (SSN)

P - Partnership: If checked, enter two partner's names and Social Security numbers (SSN). If a partner is a corporation, use the corporation's Employer Identification Number (EIN).

N - Other: If checked, explain.

O - Out-of-State CorporationName

G - Governmental EntitySSN / ITIN / EIN (9 digits)

U - State agency / University Name

F - Financial Institution SSN / ITIN / EIN (9 digits)

R - Foreign (out of U.S.A.)

Se ct io n

Se ct io n

Agency name Prepared by Phone (Area code and number)

12. Payment Assignment? YES NO Note: A copy of the assignment agreement between payees must be attached.

Assignee name

Assignee TIN Assignment date

13. Comments Authorized signature (Applicant or authorized agent) Date

14.

15.

AP-152

(Rev.8-17/17)

Application for Texas Identification Number

• See instructions on back

Who Must Submit This Application - This application must be submitted by every person (sole owner, individual recipient, partnership, corporation or other organization) who intends to bill agencies of the state government for goods, services provided, refunds, public assistance, etc. The Texas Identification Number (TIN) will be required on all maintenance submitted by state agencies. The use of this number on all billings will reduce the time required to process billings to the State of Texas.

Note: To expedite processing of this application, please return the completed application to the state agency with which you are conducting business. It is not necessary for the payee to sign or complete this form. The state agency representative may complete the form for the payee.

For Assistance - For assistance in completing this application, please call the Texas Comptroller's office at 1-800-531-5441, ext. 6-8138, or 512-936-8138.

Notice to State Agencies - When this form is used to set up additional mail codes, Sections 1, 2 and 5 must be completed. State agencies may refer to the Texas Identification Number System (TINS) Guide at https://fmx.cpa.state.tx.us/fmx/pubs/tins/tinsguide for additional information.

General Instructions -

• Do not use dashes when entering Social Security, Employer Identification, Individual Taxpayer Identification or Comptroller's assigned numbers.

• Disclosure of your Social Security number is required. This disclosure requirement has been adopted under the Federal Privacy Act of 1974

(5 U.S.C.A. sec. 552a(note)(West 1977), the Tax Reform Act of 1976 (42 U.S.C.A. sec. 405(c)(2)(C) (West 1992), TEX. GOV'T. CODE ANN. sec. 403.055 (Vernon 2005) and TEX. GOV'T. CODE ANN. sec. 403.056 (Vernon 2005). Your Social Security number will be used to help the Texas Comptroller of Public Accounts administer the state's tax laws and for other purposes.

See Op Tex. Att'y Gen. No. H-1255 (1978).

Specific Instructions - Section 1 - Texas Identification Number

EIN: For all ownership codes other than Individual Recipient listed in Section 3, enter a 9-digit Employer Identification Number (EIN) issued by the Internal Revenue Service.

SSN: For Individual Recipient or Sole Owner without an EIN, enter your 9-digit Social Security number (SSN) issued by the Social Security Administration.

ITIN: For Individual Recipient or Sole Owner without an EIN, enter your 9-digit Individual Taxpayer Identification Number (ITIN) issued by the IRS.

Comptroller Assigned Number – 11 digits: FOR STATE AGENCY USE ONLY. A Comptroller Assigned Number is an ID number that is given to a state agency that needs to pay either a foreign entity or a foreign individual who does not have an EIN, SSN or ITIN.

Current Texas Identification Number – 11 digits: FOR STATE AGENCY USE ONLY.

Are you currently reporting any Texas tax to the Comptroller's office such as sales tax or franchise tax? If "YES," enter Texas Taxpayer Number.

Section 2 - Payee Information Items 4 through 8 - Enter the complete name and mailing address where you want payments to be received. Names of individuals must be entered first name first. Each line cannot exceed 50 characters including spaces. If the name is more than 50 characters, continue the name in Item 5 and begin the address in Item 6.

Item 9 - Enter the city, state and ZIP code.

Item 10 - Enter payee telephone number.

SIC code, Security type code and Zone code: FOR STATE AGENCY USE ONLY.

Section 3 - Ownership Codes Item 11 - Check the box next to the appropriate ownership code and enter additional information as requested. Please check only one box in this section. The Secretary of State's office may be contacted at 512-463-5555 for information regarding Texas file numbers.

Section 4 - Payment Assignment Item 12 - Use when one payee is assigning payment to another payee. When setting up an assignment payment, fill out this section completely and include a copy of the assignment agreement between the assignee and the assignor.

Section 5 - Comments and Identification Item 13 - Enter any additional information that may be helpful in processing this application. Items 14 and 15 are for identification purposes. Always complete the identification section, including comments and authorized signature.

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.

Form AP-152 (Back)(Rev.8-17/17)

Fiscal Management Aust in, TX 78774-0100

G L E N N H E G A R T E X A S C O M P T R O L L E R O F P U B L I C A C C O U N T S

Application for Texas Identification Number