20-106                                                                                                                                *2010600W041516*PRINT FORM                               CLEAR FORM                   
           (Rev.4-15/16)
                                                                                                                                                 *2010600W041516*
                                                                                                                                                   *    2   0                        1   0   6   0   0 W      0   4   1   5   1   6 *  
Gross Receipts Assessment Report 
 Taxpayer number                                                                    Commission  certificate number                                                                     For Comptroller’s use only 

                                                                                                                                                          T Code                                                        90100 
                                                Taxpayer name and mailing address                                                                         Deposit Code                                                  230 

                                                                                                                                                      Check business type 
                                                                                                                                                                                   Electric            Telephone 

  Enter the annual reporting period for which this report is being filed. 
     Calendar Reporting Period                                 Reporting Period                                           Assessment Period                                                            Due Date 

                                                                   Annual                                          July         through          June                                                  August 15 

                                                                                     MONTHLY GROSS RECEIPTS 
     REPORTING PERIOD                                                                                                                                                                          QUARTERLY  TOTALS 
                                                          1st month                                  2nd month                         3rd month 
           1st Quarter                                                                                                                                                                                              $0.00

           2nd Quarter                                                                                                                                                                                              $0.00

           3rd Quarter                                                                                                                                                                                              $0.00

           4th Quarter                                                                                                                                                                                              $0.00

            Annual                                                    July               through            June                                                                                                    $0.00

                                                                                                                                                                                       1. 
  1. Enter total receipts for the year       ...............................................................................................................................           $ 
                                                                                                                                                                                       2. 
  2. TOTAL ASSESSMENT          DUE (Multiply Item 1 by .001667)                           ....................................................................................... 
  3.  Deduct authorized overpayments applied to this period                                                                                                                            3. 
        (The deduction must be net of any penalties and/or interest assessed)   .............................................................  
                                                                                                                                                                                       4. 
  4. NET  ASSESSMENT          DUE     (Item 2 minus Item 3)  .....................................................................................................
                                                                                                                                                                                       5. 
  5. Late  filling  penalty:   10%       of Item          4 if report filed  after  due  date      ................................................................................
                                                                                                                                                                                       6. 
  6. Amount due     (Item 4 plus Item 5)  ..............................................................................................................................
                                                                                                                                                                                       7. 
  7. Late  payment   interest  starting      31  days        after  due       date:   12       % per annum   simple  interest,  based  on  Item    6............. 
                                                                                                                                                                                       8. 
  8. TOTAL AMOUNT       DUE AND PAYABLE                        (Item 6 plus Item 7) .....................................................................................              $ 

          Complete this report and make amount in Item 8 payable to                                                 I declare that the above information is true and correct to the best of my 
                              STATE COMPTROLLER                                                                     knowledge and belief. 
                                                                                                                               Taxpayer or duly authorized agent 
            Mail to   COMPTROLLER OF PUBLIC ACCOUNTS 
                        111 E. 17th Street                                                                          Daytime                                                                            Date 
                        Austin,  Texas 78774-0100                                                                   phone 

                                                                    For tax   assistance            call  1-800-531-5441,  extension  3-4276.