ESBD_534725_1783434384087_SOL_EXH_F.4_AP152.pdf

SIC

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. Payee telephone number (Area code and number)

Security type code ( 0, 1, 2 )

Zone code

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

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)

Enter the number indicated

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

If "YES," enter Texas Taxpayer Number

Employer Identification Number (EIN) (9 digits)

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.

T - Texas Corporation:

If checked, enter the

Owner's name Texas File Number

SSN / ITIN (9 digits) - Professional Association:

If checked, enter the Texas

A

File Number

C - Professional Corporation:

If checked, enter the Texas File Number

Name

SSN / ITIN / EIN (9 digits)

Name

SSN / ITIN / EIN (9 digits)

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).

O - Out-of-State Corporation

G - Governmental Entity

U - State agency / University

F - Financial Institution

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

N - Other: If checked, explain.

L - Texas Limited Partnership:

If checked, enter the Texas File Number

Assignee name

Assignee TIN Assignment date

13. Comments Date

14.

Agency name Prepared by Phone (Area code and number)

15.

12. Payment Assignment? YES NO

AP-152

(Rev.7-25/19)

Application for Texas Identification Number

• See instructions on back

S e ct io n

S e ct io n

Payee Information (Please type or print)

S e ct io n

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

S e ct io n 4 Note: A copy of the assignment agreement between payees must be attached.

S e ct io n

Authorized signature (Applicant or authorized agent)

Form AP-152 (Back)(Rev.7-25/19)

Application for Texas Identification Number Instructions

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. When the application is processed by the state agency with which the applicant is conducting business, a Texas Identification Number (TIN) will be assigned and will be required on all maintenance and payment requests submitted by state agencies.

For Assistance For assistance in completing this application, contact the state agency from which the form was received or obtained. The applicant must return the completed application to the state agency with which the applicant is conducting business.

Note to State Agencies:When this form is used to set up additional mail codes after a TIN has been set up, Sections 1, 2 and 5 must be com-pleted. See FMX's TexPayment Resource (TPR) for additional information. Call Payment Services at 512-936-8138 or by email at tins.mail@cpa.texas.gov if your agency has questions about the TPR requirements and/or needs assistance for their payees in completing the application or with processing the form.

General Instructions

• Do not use dashes when entering the 9-digit Employer Identification Number (EIN), Social Security number (SSN), or Individual Taxpayer Identification Number (ITIN).

• 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

Item 1: Is this a new account?

Select YES if the applicant has never received a payment from a Texas state agency and does not have an assigned TIN.

Select NO if the applicant has received payments from a Texas state agency and already has an assigned TIN.

Mail Code / Agency number – Will be entered by the state agency that processes the application.

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) is-sued by the Internal Revenue Service (IRS).

SSN: For individuals or sole owners who choose not to apply with their EIN, enter your 9-digit Social Security number (SSN) issued by the Social Security Administration.

ITIN: For individuals who do not qualify for an SSN, enter your 9-digit Individual Taxpayer Identification Number (ITIN) issued by the IRS.

Comptroller Assigned Number (FOR STATE AGENCY USE ONLY): This 11-digit Comptroller-assigned number is provided to a state agency that needs to pay a foreign entity or a foreign individual who does not have an EIN, SSN or ITIN.

Current Texas Identification Number (FOR STATE AGENCY USE ONLY): The 11-digit current Comptroller-assigned TIN.

Section 2 — Payee Information Items 4-8: Enter the complete name and mailing address where payments are to be received. Names of individuals must be entered first name first, middle initial (if applicable), last name, suffix (if applicable). The name must not include a period (.), comma (,) or percent sign (%). 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 the payee telephone number.

SIC code / Security type code / Zone code – These fields will be completed by the state agency that will process the application.

Section 3 — Ownership Codes Item 11: Check the box next to the appropriate ownership code and enter additional information requested by the selected code. Check only one box in this section. The Texas Secretary of State's office may be contacted at 512-463-5555 for information regarding Texas File Number required for codes L, T, A and C.

Section 4 — Payment Assignment Item 12: Select YES if the payee is assigning its payments to a third party and the state agency that will process the application has ap-proved the assignment request. Also, complete the following:

• Assignee name: Provide the assignee’s name as listed on the assignment agreement. A copy of the agreement must be attached.

• Assignee TIN: Provide the assignee’s EIN if it is a business entity or an SSN or ITIN for an individual.

• Assignment date: Provide the date the assignment agreement was signed.

Select NO if the payee is not assigning its payments to a third party.

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.

Item 14: Authorized signature and Date. Sign the application, as required by the state agency that will process the form. Enter the date signed.

Item 15: Agency name, Prepared by, Phone: Will be entered by the state agency that will process the application.

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.