Form 05-177-A — Texas Franchise Tax Common Owner Information Report (Annual)

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Reporting entity taxpayer number Reporting entity taxpayer name Tcode 13257 Annual Report year (Rev.9-16/4) VE/DE Print or type name Area code and phone number ( ) - Date 1. Texas taxpayer number 2. Federal employer identification number 3. Social Security number 1. OR 2. OR 3. Blacken this circle if this entity or individual is still the common owner. Common owner start date Common owner end datem m d d y y y y m m d d y y y y (if applicable) Common owner first name, middle initial, last name Mailing address City State ZIP code Common owner business name Texas Franchise Tax Common Owner Information Report The common owner is the entity or individual that owns more than 50 percent (directly or indirectly) of each affiliate of the combined group. Note: The reporting entity is not necessarily the common owner. Common Owner Identification Identification number (Enter only ONE of the following numbers: Texas taxpayer number, federal employer identification number or Social Security number. ) Federal Privacy Act - Disclosure of your Social Security number is required and authorized under law, for the purpose of tax administration and identification of any individual affected by applicable law. 42 U.S.C. §405(c)(2)(C)(i); Tex. Govt. Code §§403.011 and 403.078. Release of information on this form in response to a public information request will be governed by the Public Information Act, Chapter 552, Government Code, and applicable federal law. Common Owner Name Dates Enter the date this entity or individual became the common owner of the combined group. (The start date is not the same as the combined group accounting period date or the privilege period.) I declare that the information in this document and any attachments is true and correct to the best of my knowledge and belief. 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 1-800-252-1381. Under Ch. 559, Government Code, you are entitled to review, request and correct information we have on file about you, with limited exceptions in accordance with Ch. 552, Government Code. To request information for review or to request error correction, contact us at the address or phone number listed on this form.