Form 05-158-A — Texas Franchise Tax Report (Long Form, Annual)

# preamble

m m d d y y Accounting year begin date ** m m d d y y Accounting year end date NAICS codeSIC code Taxpayer name Secretary of State file number or Comptroller file number Mailing address City State Country ZIP code plus 4 Blacken circle if the address has changed Blacken circle if this is a combined report Blacken circle if Total Revenue is adjusted for Tiered Partnership Election, see instructions Blacken circle if entity is Passive and/or a REIT, see instructions Passive REIT Is this entity a corporation, limited liability company, professional association, limited partnership or financial institution? Yes No Taxpayer number Report year Due date VE/DE PM Date 1. Gross receipts or sales 1. 0 0 2. Dividends 2. 0 0 3. Interest 3. 0 0 4. Rents (Can be negative amount) 4. 0 0 5. Royalties 5. 0 0 6. Gains/losses (Can be negative amount) 6. 0 0 7. Other income (Can be negative amount) 7. 0 0 8. Total gross revenue (Add items 1 thru 7) 8. 0 0 9. Exclusions from gross revenue (See instructions) 9. 0 0 (Item 8 minus item 9; if 10. TOTAL REVENUE less than zero, enter 0) 10. 0 0 , , , , . , , , , . , , , , . , , , , . , , , , . , , , , . , , , , . , , , , . , , , , . , , , , . 11. Cost of goods sold 11. 0 0 12. Indirect or administrative overhead costs 12. (Limited to 4%) 0 0 13. Other (See instructions) 13. 0 0 14. TOTAL COST OF GOODS SOLD (Add items 11 thru 13) 14. 0 0 , , , , . , , , , . , , , , . , , , , . 15. Wages and cash compensation 15. 0 0 16. Employee benefits 16. 0 0 17. Other (See instructions) 17. 0 0 18. TOTAL COMPENSATION (Add items 15 thru 17) 18. 0 0 , , , , . , , , , . , , , , . , , , , . Texas Comptroller Official Use Only Tcode Texas Franchise Tax Report - Page 1 ** If not twelve months, see instructions for annualized revenue REVENUE (Whole dollars only) COST OF GOODS SOLD (Whole dollars only) COMPENSATION (Whole dollars only)

Taxpayer number Report year Due date Taxpayer name 19. 70% revenue (Item 10 x .70) 19. 0 0 20. Revenue less COGS (Item 10 - item 14) 20. 0 0 21. Revenue less compensation (Item 10 - item 18) 21. 0 0 22. Re venue less $1 million (Item 10 - $1,000,000) 22. 0 0 (Enter the lowest of items 19, 20, 21, or 22; 23. MARGIN if less than zero, enter 0) 23. 0 0 , , , , . , , , , . , , , , . , , , , . , , , , . VE/DE PM Date Texas Comptroller Official Use Only Print or type name Area code and phone number ( ) -

24. Gross receipts in Texas (Whole dollars only) 24. 0 0 25. Gross receipts everywhere (Whole dollars only) 25. 0 0 26. APPORTIONMENT FACTOR (Divide item 24 by item 25, round to 4 decimal places) 26. , , , , . , , , , . . 27. Apportioned margin (Multiply item 23 by item 26) 27. 0 0 28. Allowable deductions (See instructions) 28. 0 0 29. TAXABLE MARGIN (Item 27 minus item 28) 29. 0 0 , , , , . , , , , . , , , , . 30. Tax rate (See instructions for determining the appropriate tax rate) 30. 31. Tax due (Multiply item 29 by the tax rate in item 30, dollars and cents) 31. . , , , , . 35. TOTAL TAX DUE (Item 33 minus item 34) 35. , , , , . 32. Tax credits (Item 17 from Form 05-181) 32. 33. Tax due before discount (Item 31 minus item 32) 33. 34. Discount (See instructions applicable to report years 2008 and 2009) 34. , , , , . , , , , . , , , , . Tcode Texas Franchise Tax Report - Page 2 MARGIN (Whole dollars only)

# APPORTIONMENT FACTOR

TAXABLE MARGIN (Whole dollars only)

# TAX DUE

TAX ADJUSTMENTS (Dollars and cents, do not include prior payments) TOTAL TAX DUE (Dollars and cents) Do not include payment if item 35 is less than $1,000 or if annualized total revenue is less than or equal to the no tax due threshold (see instructions). If the entity makes a tiered partnership election, ANY amount in it em 35 is due. Complete Form 05-170 if making a payment. I declare that the information in this document and any attachments is true and correct to the best of my knowledge and belief. Officer, director or other authorized person Date Mail original to: Texas Comptroller of Public Accounts P .O. Box 149348 Austin, TX 78714-9348 Instructions for each report year are online at www.comptroller.texas.gov/taxes/franchise/forms. For additional assistance, find contact information at www.comptroller.texas.gov/about/contact.