Free 01-153 Customs Broker Report Outlet Supplement - Texas

01-153 (1-04)

b.
DO NOT WRITE IN SHADED AREAS

PRINT FORM

CLEAR FIELDS

a. T Code

61100

Page _____ of _____
e.
f. Due date

TEXAS CUSTOMS BROKER REPORT
OUTLET SUPPLEMENT
g. Taxpayer name

c. Taxpayer number

d. Filing period

You must contact the Texas State Comptroller's field office in your area with outlet location changes or name changes. A license fee will be required for all new locations.

Physical location (outlet) name and address (Do not use a P.O. box address.)

Outlet no.

TOTALS FROM THIS OUTLET
(Dollars & cents)

1. Total value of the tangible personal property 2. Total amount of the corresponding tax for which the Customs Broker issued certifications of export 3. Total amount of tax refunded in accordance with certifications of export
Physical location (outlet) name and address (Do not use a P.O. box address.) Outlet no.

1. 2. 3. TOTALS FROM THIS OUTLET
(Dollars & cents)

1. Total value of the tangible personal property 2. Total amount of the corresponding tax for which the Customs Broker issued certifications of export 3. Total amount of tax refunded in accordance with certifications of export
Physical location (outlet) name and address (Do not use a P.O. box address.) Outlet no.

1. 2. 3. TOTALS FROM THIS OUTLET
(Dollars & cents)

1. Total value of the tangible personal property 2. Total amount of the corresponding tax for which the Customs Broker issued certifications of export 3. Total amount of tax refunded in accordance with certifications of export
Physical location (outlet) name and address (Do not use a P.O. box address.) Outlet no.

1. 2. 3. TOTALS FROM THIS OUTLET
(Dollars & cents)

1. Total value of the tangible personal property 2. Total amount of the corresponding tax for which the Customs Broker issued certifications of export 3. Total amount of tax refunded in accordance with certifications of export
Physical location (outlet) name and address (Do not use a P.O. box address.) Outlet no.

1. 2. 3. TOTALS FROM THIS OUTLET
(Dollars & cents)

1. Total value of the tangible personal property 2. Total amount of the corresponding tax for which the Customs Broker issued certifications of export 3. Total amount of tax refunded in accordance with certifications of export TOTALS FOR THIS PAGE ONLY Total value of the tangible personal property 4a. Total amount of the corresponding tax for which the Customs Broker issued certifications of export 4b. 4c.

1. 2. 3. Total amount of tax refunded in accordance with certifications of export

You have certain rights under Ch. 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 your report.