AB 01-149             HHHH                                                    PRINT FORM                     CLEAR FIELDS
                CD (Rev.5-19/9)
                                                                         b.                   *0114900W051909*
                a.    b 27160 original                                                                                Page  _____  of  _____
                c. Taxpayer number                          d. Filing period                  e.                      f. Due date
Texas Direct Pay
Tax Return      b                                                                             b
Credits Schedule

    Taxpayer name and mailing address (Make corrections next to any incorrect information.)
g.
                                                                                              I Do not staple or paper clip.
                                                                                              I Do not write in shaded areas.

                                                                                           h.    i.
                                                                                           b     b

                                                                                              PLEASE PRINT YOUR NUMERALS LIKE THIS
                                                                                              012 3456789
Examples of these credits include:
    -- mistakenly paying tax to a vendor on exempt manufacturing equipment.
    -- paying tax to the Comptroller on a non-taxable purchase.
    -- remitting tax to the Comptroller after paying sales tax to a vendor.
Local Tax
Local  tax  (city,  county,  MTA,  CTD  and  SPD  taxes)  can  be  included  in  the  credit  examples  above  only  if  the  purchaser 
reported to the same local jurisdictions as the vendor. If the local tax jurisdictions do not match, or if the jurisdiction for which 
the  local  tax  was  collected  is  not  known,  a  refund  claim  must  be  filed  for  the  local  tax.  See  Comptroller's  website  at 
www.comptroller.texas.gov/taxes/sales/refunds/  for refund instructions.

  If you answered "YES," to Item j of your Direct Payment Return, Form 01-119, you must complete Items 1 and 2, below.
         NOTE:  The data entered here is for information purposes only. It is not used in calculating tax due on this report 

  1. Amount of tax credit being taken on this return 
  (Enter dollars and cents.)                                                 b

  2. Earliest date of the tax paid in error for this credit 
  (mm-dd-yy)                                                                 b

  I declare that the information in this document and any attachments is true and correct to the best of my knowledge.
    Taxpayer or duly authorized agent                                        Date                Daytime phone (Area code & number)
  AB

                If you have any questions, call 1-800-252-5555.                             Mail to  Comptroller of Public Accounts
         Details are also available online at www.comptroller.texas.gov.                                 P.O. Box 149354
                                                                                                         Austin, TX  78714-9354

         You have certain rights under Chapters 552 and 559, Government Code, to review, request and correct information
                we have on file about you.  Contact us at the address or phone number listed on this form.