Schedule A (Form Ew1) - Pounds Of Video Display Devices Sold To Households During The Period July 1, 2013, Through June 30, 2014

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EW1

Pounds of Video Display Devices Sold to Households During the

Period July 1, 2013, Through June 30, 2014

Schedule A

You may choose to report the total weight of each specific model of VDDs sold to Minnesota households during the previous program

year (Option 1) OR estimate of the total weight of VDDs sold to Minnesota households based on national sales data (Option 2) . Be sure to

explain below how the actual weight or estimated weight of VDDs was calculated .

Business Name

Minnesota Tax ID Number

Federal ID Number (FEIN)

Minnesota Sales (Option 1)

Retailer

Brand/Model

Pounds Per Model

Number Sold

Total Weight*

1 Total weight of Minnesota sales (enter amount here and on line 4 below; skip lines 2 and 3) . . . . . . . . . . . . . . . . . . . . . 1

National Sales (Option 2)

Brand/Model

Pounds Per Model

Number Sold

Total Weight*

2 Total weight of national sales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Multiply line 2 by 1 .72% (0 .0172), which is Minnesota’s percentage of the national population . . . . . . . . . . . . . . . . . . . 3

4 Enter the total from line 1 or line 3 . Also enter this amount on Form EW1, line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

* You must explain below how the actual weight or estimated weight of VDDs was calculated .

Send in this schedule with Form EW1.