PRINT FORM           CLEAR FIELDS
          01-114
          (Rev.4-19/40)                                                                                                                                                                     Instructions in English
                                                                                                                                     b.
a.    
                                                                                                                                                                                                                     Page 1 of
c. Taxpayer number
                                                                d. Filing period                                                                                           e.                          f. Due date
                                                                  DDDD
                                                                Do not staple or paper clip. Do not write in shaded areas.
Texas Sales and Use Tax Return                                                                                                                             See instructions, Form 01-922.Blacken this box if your mailing
          26100
                                              Taxpayer name and mailing address                                                                                                       address has changed. Show changes
g.                                                                                                                                                                                    by the preprinted information.           1.
                                                                                                                                                                                      Blacken this box if you are no longer
                                                                                                                                                                                      in business. Write in the date you went
                                                                                                                                                                                      out of business.                         2.
                                                                                                                                                                                      Blacken this box if one of your
                                                                                                                                                                                      locations is out of business or has
                                                                                                                                                                                      changed its address.                     3.
                            under Chapters 552 and 559, Government Code, to review, request and correct                                                                          h.      i.
information we have on file about you.  Contact us at the address or phone numbers indicated in the instructions.                                                                    *0111400W041940*

                                                                                                                                              l. l. NO SALES -                                                                 1
You have certain rights
j. Are you taking credit to reduce taxes due on this 
      return? If you are claiming bad debt credit to reduce YES   NO
      your tax due, you must file electronically.      1          2                                                                           PLEASE PRINT YOUR If you had zero to report in Items 1, 2 and 3 for ALL locations
k. Did you refund sales tax for items exported outside                                                                                        forNUMERALS LIKE THIS                                                            this filing period, blacken this box, sign and date this return and mail it 
      the U.S. based on a Texas Licensed Customs       YES        NO                                                                          to the Comptroller's office.
      BrokerReturnExport Certificate?                  1          2                                                               6. Physical location (outlet) name and address      Outlet                                        MUST be filed even if no tax is due.
                                                                                                                                      (Do not use a P.O. box address.)                no.

1. TOTAL TEXAS SALES                 (Blacken appropriate box)                                                                                                                                                               R
    (Whole dollars only)
          If you answered yes to either question j or k, you must complete 
      2. TAXABLE SALESForm 01-148 and submit it with your return.
          (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
          (Item 2 plus Item 3)                                                                                                    X           .062500                                =
      5. Amount subject to local tax
          (Amount for city, transit, bbbb                                                                                                                                             7b.Local tax (include in Item 8b)
          county and SPD must 
          be equal.)                                                                                                              X                                                  =

                                                                                     STATE TAX - Column a                                                                                 LOCAL TAX - Column b

       8. Total tax due (from all outlets or list supplements)

          01-114 26180b
          (Rev.4-19/40)                                           _
       9. Prepayment credit
      b(Item 8 minus Item 9)                                      =                                                                  b b
      10. Adjusted tax due 
                                                                  _
      11. Timely filing discount (0.005)
                                                                  _
      12. Prior payments             DDDD
      13. Net tax due (Item 10 minus Items 11 and 12)             =
      14. Penalty and interest (See instructions)                 +                                                                                                  . ..
                                                                       15a. Total state amount due                                                                                    15b. Total local amount due
                                                                                                                                                                     .
      15. TOTAL STATE AND LOCAL AMOUNT DUE 
             (Item 13 plus Item 14)                              =
                 Mail to:  Comptroller of Public Accounts                                                                                                            . ..
                               P.O. Box 149354
                               Austin, TX  78714-9354                                                                                                                .
      T Code                  Taxpayer number                                                                              Period             16. TOTAL 
                                                                                                                                                           AMOUNT(Total of ItemsPAID 
                                                                                                                                                     15a and 15b)
Taxpayer name                                                      bn.                                                                                                                                                   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                                  Make check payable to: 
26020                                                                                                                                                                                 STATE COMPTROLLER.
                                                                                                                                                                  (Area code & number)