Idaho Application for Amusement Device Permit

Application for Amusement Device Permit
Form ADT, Application for Amusement Device Permit
Form ADT
Application for Amusement Device Permit
State Use Only

Mail application and payment to:
Idaho State Tax Commission
PO Box 36
Boise ID 83722-0410

Use this application for amusement device permits (decals). You must display decals on each currency- or tokenoperated amusement device in service. Examples: pinball machine, jukebox, video game, etc.
Legal business name

Assumed business name

Mailing address

Employer Identification Number (EIN )

City

State

ZIP code

Social Security number (SSN)

Business phone number

Contact Person Information
Name

Title

Phone number and extension

Email address

Fax number

Section 1
1. Purpose of registration (select one):
New applicant

Change legal name

Change assumed business name

Add/Change location

Change in partners, shareholders, or managing members

2. Enter your active Idaho seller’s permit number, if applicable.
If you have a current Idaho seller’s permit and information about your business hasn’t changed, go to section 2.
3. Date business began in Idaho 4. Date incorporated
5. State of incorporation
6. Month tax year ends
7. Describe your business activities in Idaho. Include the date the activities began in Idaho.

8. Have you ever had a permit or account number issued by us?
Yes

If yes, list all permit or account numbers.

No

9. Type of business (select one):
Sole proprietorship

Partnership

S corporation

Corporation

Nonprofit

Government

Fiduciary or trust

Limited liability company

10. List (a) owner and spouse of sole proprietorship, (b) all partners of partnership, (c) all corporate officers for a
corporation, or (d) all members for an LLC. (Use additional sheet, if necessary.)
Name

EFO00148

08-21-2020

Address of residence

SSN or EIN and phone number

Corporate
Title

%
Owned

Director?
yes/no

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Form ADT

(continued)

Section 2
11. List the business’s physical location - No PO Box or mail drop addresses
(Use additional sheet, if necessary.)
Street address

City

State

ZIP code

Street address

City

State

ZIP code

Street address

City

State

ZIP code

12. If you operate amusement devices at locations other than your own business, please include below.
(Use additional sheet, if necessary.)
Device 1
Street address

City

State

ZIP code

City

State

ZIP code

City

State

ZIP code

Device 2
Street address

Device 3
Street address

Section 3
13. Enter the number of amusement device decals requested. See instructions for decal requirements.
Number of decals for machines or devices in service

x $42.00 =

Total Due

Section 4
Complete the applicable section if you’re requesting a transfer of existing decals (see instructions for transfer types).
14. Are you the new owner of a business with existing decals registered to the previous owner?

Yes

No

Enter the previous owner’s name:
Enter the date you acquired the business:
List of decals to be transferred:

15. Did you change the name of your business?

Yes

No

Provide your business’s previous name:
List of decals to be transferred:

Certification: I certify that I am authorized as an owner, partner, corporate officer, member, or representative to sign
this document and that the statements made are correct and true to the best of my knowledge. (For sole proprietors, the
spouse must also sign this form.)
Print name

Signature

Date

Print name

Signature

Date

EFO00148

08-21-2020

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