01-116-A                                                                                                                         PRINT FORM  CLEAR FIELDS
        (Rev.4-19/16)                                                             FFFF
                                                                                                                                               Instructions in English
                                                                                                                                      *01116A0W041916*
Texas List Supplement
- SALES AND USE TAX -                                                                                                                         FILING REQUIREMENTS
                                   c. Taxpayer                                                               d. Filing period                                         e.
a.    b 26120                          number  b                                                                                                                      b
f. Taxpayer name                                                                                                                                     g. Due date

                                                                                                                                            I PRINT YOUR NUMERALS LIKE THIS
I Do not staple or paper clip.                                                                                                              012 3 45 67 89

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

        ** 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.