Form 05-169-A — Texas Franchise Tax Report (E-Z Computation, Annual)

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Taxpayer number Report year Due date Taxpayer name 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 Passive REITand/or a REIT, see instructions Yes No Tcode NAICS code Accounting year Accounting year begin date ** end date m m d d y y m m d d y y 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 8.(Add items 1 thru 7) 0 0 9. Exclusions from gross revenue 9.(see instructions) 0 0 10. TOTAL REVENUE 10.(item 8 minus item 9 if less than zero, enter 0) 11. Gross receipts in Texas 11. 0 0 12. Gross receipts everywhere 12. 0 0 13. Apportionment factor (Divide item 11 by item 12) (Round to 4 decimal places) 13. 14. Apportioned revenue 14.(Multiply item 10 by item 13) (Dollars and cents) 15. Tax due before discount (Multiply item 14 by 0.00331) (Dollars and cents) 15. 16.16. Discount (see instructions, applicable to report years 2008 and 2009) 17. TOTAL TAX DUE (item 15 minus item 16) (Do not include payment if this amount is less than $1,000) 17. 0 0 Print or type name Area code and phone number ( ) - VE/DE PM Date Texas Franchise Tax EZ Computation Report REVENUE (Whole dollars only, items 1 -12) Do not include payment if item 17 is less than $1,000 or if annualized total revenue is less than the no tax due threshold (see instructions). If the entity makes a tiered partnership election, ANY amount in item 17 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. 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/. If you have any questions, call 800-252-1381. ** If not 12 months, see instructions for annualized revenue.