01-116-A (Rev.3-08/13)
PRINT FORM
CLEAR FIELDS
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Instructions in English
TEXAS LIST SUPPLEMENT - SALES AND USE TAX a.
FILING REQUIREMENTS
d. Filing period e.
26120
c. Taxpayer number
f. Taxpayer name
g. Due date
PRINT YOUR NUMERALS LIKE THIS
Do not staple or paper clip. Do not write in shaded areas.
1. CITY/TRANSIT/COUNTY /SPD NAME
2. CITY/TRANSIT/ COUNTY/SPD NO.
3. AMOUNT SUBJECT TO TAX
(Whole dollars only)
4. TAX RATE
(Multiply Item 3 by Item 4)
5. AMT. OF TAX DUE
LOCAL TAX
7b. TOTAL DUE ON THIS PAGE
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 toll-free number listed on this form.