01-115
      (Rev.4-19/25)                              EEEE                                                                 PRINT FORM         CLEAR FIELDS
TEXAS SALES AND USE TAX RETURN                                  b.                                                 *0111500W041925*      Instructions in English
      - OUTLET SUPPLEMENT -
                                                                                                                                     Page              of
                         c. Taxpayer                                        d. Filing period                                             e.
a.    26100                  number
Make any necessary changes next to the incorrect information for any location. (Do not use P.O. box addresses.)
f. Taxpayer name                                                                                                                         g. Due date

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

      SEE INSTRUCTIONS FORM 01-922
                                                      6. Physical location (outlet) name and address                          Outlet 
                                                          (Do not use a P.O. box address.)
1. TOTAL TEXAS SALES                                                                                                          no.
    (Whole dollars only)
2. TAXABLE SALES
    (Whole dollars only)
                                                      7. AMOUNT OF TAX DUE FOR THIS OUTLET                            (Dollars and cents)
3. TAXABLE PURCHASES                                      (Multiply "Amount subject to tax" by "TAX RATE" for state and local tax due)
    (Whole dollars only)                                               TAX RATES
4. Amount subject                                                                                                     7a.State tax (include in Item 8a)
    to state tax                                                          .062500
    (Item 2 plus Item 3)
5. Amount subject to local tax                        X                                                           =   7b.Local tax (include in Item 8b)
    (Amount for city, transit, 
    county and SPD must 
    be equal.)                                        X                                                           =
                                                      6.(DoPhysicalnot uselocationa P.O.(outlet)box address.)name and address Outlet 
                                                          
1. TOTAL TEXAS SALES                                                                                                          no.
    (Whole dollars only)
2. TAXABLE SALES
    (Whole dollars only)
                                                      7. AMOUNT OF TAX DUE FOR THIS OUTLET                            (Dollars and cents)
3. TAXABLE PURCHASES                                      (Multiply "Amount subject to tax" by "TAX RATE" for state and local tax due)
    (Whole dollars only)                                               TAX RATES
4. Amount subject                                                                                                     7a.State tax (include in Item 8a)
    to state tax                                                          .062500
    (Item 2 plus Item 3)
5. Amount subject to local tax                        X                                                           =   7b.Local tax (include in Item 8b)
    (Amount for city, transit, 
    county and SPD must 
    be equal.)                                        X                                                           =

                                                      6.(DoPhysicalnot uselocationa P.O.(outlet)box address.)name and address Outlet 
                                                          
1. TOTAL TEXAS SALES                                                                                                          no.
    (Whole dollars only)
2. TAXABLE SALES
    (Whole dollars only)
                                                      7. AMOUNT OF TAX DUE FOR THIS OUTLET                            (Dollars and cents)
3. TAXABLE PURCHASES                                      (Multiply "Amount subject to tax" by "TAX RATE" for state and local tax due)
    (Whole dollars only)                                               TAX RATES
4. Amount subject                                                                                                     7a.State tax (include in Item 8a)
    to state tax                                                          .062500
    (Item 2 plus Item 3)
5. Amount subject to local tax                        X                                                           =   7b.Local tax (include in Item 8b)
    (Amount for city, transit, 
    county and SPD must 
    be equal.)                                        X                                                           =
                                                      6.(DoPhysicalnot uselocationa P.O.(outlet)box address.)name and address Outlet 
                                                          
1. TOTAL TEXAS SALES                                                                                                          no.
    (Whole dollars only)
2. TAXABLE SALES
    (Whole dollars only)
                                                      7. AMOUNT OF TAX DUE FOR THIS OUTLET                            (Dollars and cents)
3. TAXABLE PURCHASES                                      (Multiply "Amount subject to tax" by "TAX RATE" for state and local tax due)
    (Whole dollars only)                                               TAX RATES
4. Amount subject                                                                                                     7a.State tax (include in Item 8a)
    to state tax                                                          .062500
    (Item 2 plus Item 3)
5. Amount subject to local tax                        X                                                           =   7b.Local tax (include in Item 8b)
    (Amount for city, transit, 
    county and SPD must 
    be equal.)                                        X                                                           =

                                                      STATE TAX                                                       LOCAL TAX
                 TOTAL TAX DUE  ON THIS PAGE
                         (For Taxpayer Use Only)

                         You have certain rights                                                                                                                   under Ch. 559, Government Code, to review, request and correct information
                               we have on file about you.  Contact us at the address or phone number listed in the instructions.