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4909, Page 2

Taxpayer FEIN

PART 1: FRANCHISE TAX — Continued

A. As Originally Filed

or Previously Amended

B. Correct Amount

17. Add lines 16A, 16B, 16C, 16D and 16E. If less than zero, enter zero here and on

line 20; skip to line 20 ................................................................................................ 17.

18. Net Capital for Current Taxable Year. Divide line 17 by number of tax years

reported in lines 10 through 16, columns A through E. (UBGs, see instructions) ...... 18.

19. Apportioned Tax Base. Multiply line 18 by percentage on line 9c ............................. 19.

20. Tax Liability. Multiply line 19 by 0.29% (0.0029). If less than or equal to $100,

enter zero .................................................................................................................. 20.

21. Recapture of Certain Business Tax Credits from Form 4902, line 20 ..........................

21.

22. Total Tax Liability. Add lines 20 and 21 ................................................................... 22.

PART 2: PAYMENTS AND TAX DUE

23. Overpayment credited from prior return (MBT or CIT) .............................................. 23.

24. Estimated tax payments ............................................................................................ 24.

25. Flow-Through Withholding payments ........................................................................ 25.

26. Tax paid with request for extension ........................................................................... 26.

27. Amount paid with original return plus additional tax paid after original return was filed ........................................

27.

28. Total Payments. Add line 23, column B, through line 27 .......................................................................................

28.

29. Overpayment, if any, received on the original return or previous amended return ................................................

29.

30. Subtract line 29 from line 28 ..................................................................................................................................

30.

31. TAX DUE. Subtract line 30 from line 22, column B. If less than zero, leave blank ................................................

31.

32. Underpaid estimate penalty and interest from Form 4899, line 38 ........................................................................

32.

33. Annual Return Penalty (see instructions) ..............................................................................................................

33.

34. Annual Return Interest (See instructions)..............................................................................................................

34.

35. PAYMENT DUE. If line 31 is blank, go to line 36. Otherwise, add lines 31, 32, 33 and 34 ..................................

35.

PART 3: REFUND OR CREDIT FORWARD

36. Overpayment. Subtract line 22, column B, and lines 32, 33 and 34 from line 30. If less than zero, leave blank

(see instructions) ...................................................................................................................................................

36.

37. CREDIT FORWARD. Amount on line 36 to be credited forward and used as an estimate for next tax year ............. 37.

38. REFUND. Subtract line 37 from line 36 .................................................................................................................

38.

Taxpayer Certification.

Preparer Certification.

I declare under penalty of perjury that the information in

I declare under penalty of perjury that this

this return and attachments is true and complete to the best of my knowledge.

return is based on all information of which I have any knowledge.

Preparer’s PTIN, FEIN or SSN

By checking this box, I authorize Treasury to discuss my return with my preparer.

Authorized Signature for Tax Matters

Preparer’s Business Name (print or type)

Authorized Signer’s Name (print or type)