01-116-C
      (Rev.4-19/16)                                                               FFFF                                                       PRINT FORM            CLEAR FIELDS
                                                                                                                                       *01116C0W041916*
Texas List Supplement
- DIRECT PAYMENT USE TAX -                                                                                                   *** INTERNET ***
                                   c. Taxpayer                                                                d. Filing period                                     e.
a.    27120                            number
f. Taxpayer name                                                                                                                                      g. Due date

                                                                                                                                             PRINT YOUR NUMERALS LIKE THIS
Do not staple or paper clip.

1. CITY/TRANSIT/COUNTY/SPD NAME                      COUNTY/SPD2. CITY/TRANSIT/NO.     3. AMOUNT(WholeSUBJECTdollars only)TO TAX          4. TAX RATE   (Multiply5. AMT.ItemLOCAL3 byTAXItem 4)DUE

                                                                                  PLEASE NOTE:
                                             You cannot file this supplement unless you hold a Texas Direct 
                                                     Payment Permit, issued by the Comptroller's office.
                                                                                           
                                                                                  CLICK HERE TO CONTINUE

      ** Jurisdictions with two asterisks 
                 (        **) next to them indicates                                                                             LOCAL TAX
                 you have at least one outlet 
                 within that jurisdiction. You       7b. TOTAL DUE ON THIS PAGE
                 must include the amount 
                 subject to tax for that outlet(s),  You have certain rights under Chapters 552 and 559, Government Code, to review, request and correct 
                 even if the amount is zero.         information we have on file about you.  Contact us at the address or phone number listed in the instructions. 

Form 01-116-C (Back)(Rev.4-19/16)

                                     INSTRUCTIONS FOR COMPLETING
                                 Texas Direct Payment Use Tax Return
                                        List Supplement

Who must file the list supplement? If you hold a Direct Payment Use Tax Permit, you must file the List Supplement to report and
pay the tax required on taxable purchases on which the tax was not paid to the supplier as required under Tax Code 151.101.

Instructions for filing amended Texas Direct Payment Use Tax Returns - To request forms to file an amended return, call 
1-800-252-5555. Forms may be picked up at the Comptroller field office nearest you.
OR
You may photocopy  the original, write "AMENDED RETURN" at the top,   strike through Item a, strike through those figures that
have changed and write the new figures on the return.  Sign and date the amended return.

Whom to contact for assistance - If you have any questions regarding the Direct Payment Use Tax, you may contact the Texas 
State Comptroller's field office in your area, or call 1-800-252-5555.

Item c. Taxpayer  Number  -  If  the  return  is  not  preprinted,    Item 3. AMOUNT SUBJECT TO TAX - Tax must be paid on
  enter  the  taxpayer  number  shown  on  your  Direct                       any taxable purchases on which the tax was not paid
  Payment  Use  Tax  Permit.  If  you  have  not  received                    to the supplier. If this amount is negative, bracket the
  your  tax  permit,  enter  the  Federal  Employer                           amount as follows:  <xx,xxx>.
  Identification  Number  (FEIN)  assigned  to  your 
  organization.                                                       Item 4. TAX  RATE  -  Tax  rate  is  the  local  tax  rate  ranging
                                                                              from  1/4  of  1  percent  to  2  percent.  If  the  form  is
Item d. Filing Period - Filing period should be entered if your               preprinted, the tax rate for each local jurisdiction will
  report is not already preprinted. Enter the filing period                   be  printed  on  the  form.  If  the  tax  rate  is  not  pre-
  of  this  return  and  the  last  day  of  the  month  in  the              printed, check the booklet, Texas Sales and Use Tax
  space provided. Example: "Month Ending 03-31-08."                           Rates (96-132), and enter the appropriate tax rate in
                                                                              this column. 
Item 1. CITY/TRANSIT/COUNTY/SPD  NAME  -  City/Transit/
  County/SPD  names  will  be  preprinted  here.  List                Item 5. AMOUNT OF TAX DUE - To calculate  the  tax  due,
  additional cities, transit authorities, counties or SPDs                    multiply the amount subject to tax (Item 3) by the tax
  where you did business during the reporting period.                         rate (Item 4). If this amount  is negative,  bracket  the
                                                                              amount as follows:  <xxx.xx>.
Item 2. CITY/TRANSIT/COUNTY/SPD NO. - The seven digit
  number  for  the  local  taxing  jurisdiction  will  be  pre-       Item 7b. TOTAL DUE ON THIS PAGE -    Add  the amounts  in
  printed  beside  the  appropriate  city,  transit authority,                Column  5  and  enter  the  total in Item 7b.  Then  total
  county or SPD name. If the local jurisdiction name in                       the local tax (7b) from all pages and enter in Item 2b,
  Item 1  is not  preprinted,  refer  to the  booklet,  Texas                 Column  b,  of  the  Texas  Direct  Payment  Use  Tax
  Sales  and  Use  Tax  Rates  (96-132)  and  enter  the                      Return  (Form  01-119).  If  this  amount  is  negative,
  appropriate number.                                                         bracket the amount as follows:  <xxx.xx>.

                                   MAKE COPIES FOR YOUR RECORDS