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RESET FORM PRINT FORM Texas Franchise Tax EZ Computation Report 05-169 Rev.9-16/8 FILING REQUIREMENTS Tcode 13272 Final Final Taxpayer number Report year Due date Mailing address City State Blacken circle if this is a combined report Tiered Partnership Election see instructions m d y Accounting year begin date Country ZIP code plus 4 address has changed Account Status NAICS code end date REVENUE Whole dollars only items 1 -12 1. Gross receipts or sales 2. Dividends 3. Interest 4. Rents can be negative amount 5. Royalties 6. Gains/losses can be negative amount 7. Other income can be negative amount 8. Total gross revenue Add items 1 thru 7 9. Exclusions from gross revenue see instructions 10. TOTAL REVENUE item 8 minus item 9 if less than zero enter 0 10. 13. Apportionment factor Divide item 11 by item 12 Round to 4 decimal places 14. Apportioned revenue Multiply item 10 by item 13 Dollars and cents 15. Tax due before discount Multiply item 14 by 0. 00331 Dollars and cents 16. Discount see instructions applicable to report years 2008 and 2009 17. TOTAL TAX DUE item 15 minus item 16 Do not include payment if this amount is less than 1 000 Do not include payment if item 17 is less than 1 000 or if annualized total revenue is less than the no tax due threshold see instructions. If the entity makes a tiered partnership election ANY amount in item 17 is due. Complete Form 05-170 if making a payment. Print or type name Area code and phone number I declare that the information in this document and any attachments is true and correct to the best of my knowledge and belief* Date - Mail original to Texas Comptroller of Public Accounts P. O. Box 149348 Austin TX 78714-9348 Instructions for each report year are online at www. comptroller. texas. gov/taxes/franchise/forms/. If you have any questions call 1-800-252-1381. If not 12 months see instructions for annualized revenue. Gross receipts or sales 2. Dividends 3. Interest 4. Rents can be negative amount 5. Royalties 6. Gains/losses can be negative amount 7. Other income can be negative amount 8. Total gross revenue Add items 1 thru 7 9. Exclusions from gross revenue see instructions 10. Other income can be negative amount 8. Total gross revenue Add items 1 thru 7 9. Exclusions from gross revenue see instructions 10. TOTAL REVENUE item 8 minus item 9 if less than zero enter 0 10. 13. Apportionment factor Divide item 11 by item 12 Round to 4 decimal places 14. TOTAL REVENUE item 8 minus item 9 if less than zero enter 0 10. 13. Apportionment factor Divide item 11 by item 12 Round to 4 decimal places 14. Apportioned revenue Multiply item 10 by item 13 Dollars and cents 15. Tax due before discount Multiply item 14 by 0. Apportioned revenue Multiply item 10 by item 13 Dollars and cents 15. Tax due before discount Multiply item 14 by 0. 00331 Dollars and cents 16. Discount see instructions applicable to report years 2008 and 2009 17. TOTAL TAX DUE item 15 minus item 16 Do not include payment if this amount is less than 1 000 Do not include payment if item 17 is less than 1 000 or if annualized total revenue is less than the no tax due threshold see instructions.

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