789201 Taxable receipts Report dollars and centsh IMPORTANTg Name and mailing address Make any necessary name or address changes belowBlacken this box if your mailing address has changed Show changes ID: 886375
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1 78920 c/c12. Total receipts subject to
78920 c/c12. Total receipts subject to tax and/or surcharge 2a.2b.2c. (Total of Items 1a through 1h)3. Tax rate3a.0.062503b.0.025003c.0.010004. Tax and/or surcharge due 4a.(Multiply Item 2 by Item 3)4b.4c.5. Total amount of surcharge (Add Items 4b and Item 4c)5c.6. Prepayments 6a.(See instructions)6c.7. Net tax / surcharge due 7a.7c.(Subtract Item 6a from Item 4a; subtract Item 6c from Item 5c)8. Discount 1. Taxable receipts (Report dollars and cents) h. IMPORTANTg. Name and mailing address (Make any necessary name or address changes below.)Blacken this box if your mailing address has changed. Show changes1.by the preprinted information.Blacken this box if you are no longer 2.date you went out of business.Month Day
2 YearABCBCBDi.j. a. 78100c. Taxpay
YearABCBCBDi.j. a. 78100c. Taxpayer number b.*1411700W121815* d. Filing periode.f. Due date CountyGross Receipts Taxpayer namem. T CodeTaxpayer number Period I declare that the information in this document and any attachments is true and correct to the best of my knowledge and belief.Duly authorized agent (PLEASE PRINT NAME)Business phoneDate333 C I 14-117(Rev.12-18/15) (TEX. TAX ANN. sec. 152.047 and 152.048)Items 1a - 1h - County NameGross Receipts CollectedReceipts Subject to 1.0% Surcharge NOTE: If Item 4a is GREATER than Item 6a, multiply the difference by 1/2 of 1% (0.005) and enter the result in Item 8a.NOTE: An additional $50 late filing penalty will be assessed each time a report is filed after the due date