Fillable Cop 102 COP 102 (Harris County Tax Office)

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Cop 102 COP 102 (Harris County Tax Office)

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COP-102 www.hctax.net Rev. 3/13 v.5
Coin Operated Machine Permit Application
BUSINESS INFORMATION
State ID Number:
Harris County Account Number:
Business Name: (Last, then first, if individual)
Physical Address: (No P.O. Boxes)
City:
State:
Zip:
Daytime Phone:
OWNER INFORMATION (if different from Business)
Owner Name: (Last, then first, if individual)
Physical Address: (No P.O. Boxes)
City:
State:
Zip:
Daytime Phone:
Permits Requested
Please complete the information below, indicating each location for which a permit is requested.
# PERMITS
LOCATION NAME
LOCATION ADDRESS
ZIP CODE
I declare under penalties prescribed by the general and specific laws of Texas that the information provided herein are
true and correct.
Signature: Date:
Printed Name: Title:
Make checks payable to: Ann Harris Bennett, Harris County Tax Assessor-Collector
Permit purchased between:
Fee:
January 1st - March 31st
$15.00
April 1st - June 30th
$11.25
July 1st - September 30th
$7.50
October 1st - December 31st
$3.75
Mail with check or Money Order to:
Harris County Tax Assessor-Collector
P.O. Box 4663
Houston, Texas 77210-4663
Attn: Coin-Operated Machines
H
a
r
r
i
s
Total Permits:
Total Amount Paid:
Tax Assessor-Collector & Voter Registrar
ANN HARRIS BENNETT
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Cop 102 COP 102 (Harris County Tax Office)

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Completed 20 July 2020

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