Form 01-114 — Texas Sales and Use Tax Return (Standard)

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DDDD _ 9. Prepayment credit 10. A d j usted ta x due (Ite m 8 min u s Ite m 9 ) = . . _11. Timely filing discount (0.005) . . _12. Prior payments =13. Net ta x due (Item 10 minus Items 11 and 12) . . +14. Penalty and interest (See ins t r uct i o ns ) . . 15a. Total state amount due 15b. Total local amount due 15. TOT A L ST A TE A ND LOC A L A MOUNT DUE (Ite m 1 3 p l u s Ite m 1 4 ) = b b 7. AMOUNT OF TAX DUE FOR THIS OUTLET (Dollars and cents) (Multiply "Amount subject to tax" by "TAX RATE" for state and local tax due) TA X RATES 7a.State ta x ( in c l ude in Ite m 8a ) X = . 7b.Local ta x ( in c l ude in Ite m 8b ) X = . 6. Physical location (outlet) name and address Outlet (Do not use a P.O. box address.) no. b b Daytime phone ( A r e a code & n u mb e r ) b b b Ta x payer name o. b T Code Taxpayer number Period 16. TOTAL AMOUNT PAID 26020 (Total of Items 15a and 15b) b 26180 b ST A TE T A X - Column a b LOC A L T A X - Column b 8. Total ta x due (f r o m all out l et s o r lis t s u pp l e m e n t s ) 1. TOTAL TEXAS SALES (Whole dollars only) b 2. TAXABLE SALES (Whole dollars only) b 3. TAXABLE PURCHASES (Whole dollars only) b4. Amount subject to state tax (Item 2 plus Item 3) b5. Amount subject to local tax (Amount for city, transit, county and SPD must be equal.) b I Blacken this box if your mailingTaxpayer name and mailing address address has changed. Show changesg. by the preprinted information. 1. b I Blacken this box if you are no longer in business. Write in the date you went out of business. 2. bI Blacken this box if one of your locations is out of business or has changed its address. 3. b h. i. b b DDDD b. b *0111400W082541* See instructions, Form 01-922. n. NO SALES - If you had zero to report in Items 1, 2 and 3 for ALL locations 1 for this filing period, blacken this box, sign and date this return and mail it Rto the Comptroller's office. b

Page 1 of AB CD c. Taxpayer number a. d. Filing period e. f. Due date j. Are you taking credit to reduce taxes due on this return? If you are claiming bad debt credit to reduce YES NO your tax due, you must file electronically. 1 b 2 bk. Did you refund sales tax for items exported outside the U.S. based on a Texas Licensed Customs YES NO Broker Export Certificate? 1 b 2 bl. Are you taking credit to reduce taxable sales on this return for the purchase of Texas farm-raised YES NO oysters? 1 b 2 bm. Are you taking credit to reduce taxable sales on this return for participation in a qualified oyster YES NO shell recycling program? 1 b 2 b (Rev.8-25/41) Texas Sales and Use Tax Return I Do not staple or paper clip. I Do not write in shaded areas. You have certain rights under Chapters 552 and 559, Government Code, to review, request and correct information we have on file about you. Contact us at the address or phone numbers indicated in the instructions. If you answered yes to either question j - m, you must complete Form 01-148 and submit it with your return. Return MUST be filed even if no tax is due. PLEASE PRINT YOUR

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(Rev.8-25/41) Mail to: Comptroller of Public Accounts P.O. Box 149354 Austin, TX 78714-9354 I declare that the information in this document and any attachments is true and correct to the best of my knowledge.AB Taxpayer or duly authorized agent Date Make check payable to: STATE COMPTROLLER.