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FORM 401C BUSINESS ACTIVITY TAX RETURN-COAL Please Check Appropriate Box TIN/SSN Separate Return Combined Return Check box if AMENDED and enter correct Reporting Period below being amended Taxpayer Name ONTC Reporting Period Quarter Due 45 days after end of Quarter Mailing Address OFFICE USE ONLY Business Activity Check here if mailing address has changed. RELATED BRANCH INFORMATION Form 404 must be filed if one of a group of related branches. Gross Receipts Enter Whole Dollars 1. Navajo goods. 2. Navajo services. 3. Total gross receipts Add Line 1 and Line 2. Deductions 4. Standard deduction - 125 000 or 10 of Line 3. - 5. Salaries wages other compensation paid to Navajos Form 402. 6. Purchases of Navajo goods Form 403 - Part A. - 7. Purchases of Navajo services Form 403 - Part B. 8. Payments made to the Navajo Nation government Form 403 - Part C. 9. Total Deductions Add Lines 4 through 8. 10. Navajo source gains Line 3 less Line 9. 11. Business Activity Tax Line 10 times 5. 12. Credit for State Taxes Paid on Coal Sales Form 405. 13. Tax paid with extension request Form 145 must have been timely filed. 14. Interest s - if applicable. Calculate interest owed enter amount attach calculations. 15. Penalty s - if applicable. Calculate penalties owed and enter amount attach calculations. 16. TOTAL TAXES DUE. For payments under 10 000 make check payable to the order of mail to Payments over 10 000 must be wire transferred to the following account Office of the Navajo Tax Commission Post Box 1903 Window Rock Arizona 86515-1903 Phone 928 871-6681 Fax 928 871-7608 The Navajo Nation Account Number 4000901560 Wells Fargo Bank - Window Rock Branch Bank Routing Number 091000019 payment is made by wire transfer Amount I declare that the information contained in this document and any attachments thereto is true and correct to the best of my knowledge and belief pursuant to all Navajo Nation laws and regulations. x Taxpayer or Duly Authorized Agent Signature Print or Type Name BAT- Form 401-C Telephone Number / Date Revised 2/12/2002. Gross Receipts Enter Whole Dollars 1. Navajo goods. 2. Navajo services. 3. Total gross receipts Add Line 1 and Line 2. Deductions 4. Standard deduction - 125 000 or 10 of Line 3. - 5. Salaries wages other compensation paid to Navajos Form 402. Deductions 4. Standard deduction - 125 000 or 10 of Line 3. - 5. Salaries wages other compensation paid to Navajos Form 402. 6. Purchases of Navajo goods Form 403 - Part A. - 7. Purchases of Navajo services Form 403 - Part B. 6. Purchases of Navajo goods Form 403 - Part A. - 7. Purchases of Navajo services Form 403 - Part B. 8. Payments made to the Navajo Nation government Form 403 - Part C. 9. Total Deductions Add Lines 4 through 8. 8. Payments made to the Navajo Nation government Form 403 - Part C. 9. Total Deductions Add Lines 4 through 8. 10. Navajo source gains Line 3 less Line 9. 11. Business Activity Tax Line 10 times 5. 12. Credit for State Taxes Paid on Coal Sales Form 405. 10. Navajo source gains Line 3 less Line 9. 11. Business Activity Tax Line 10 times 5. 12. Credit for State Taxes Paid on Coal Sales Form 405. 13. Tax paid with extension request Form 145 must have been timely filed. 14. Interest s - if applicable.

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