Primary Source Suppliers Monthly Report {55570}

State Form 55570 (R / 5-14) ALC-PS Form Primary Source Suppliers Monthly Report Reporting Month _______________ Year __________ Indiana Department of Revenue Amended Return No Activity This return must be postmarked on or before the 10th day of the month following the reporting month. Section A: Taxpayer Information Name (As It Appears on Permit) Physical Address/City/State/ZIP Mailing Address/ City/State/ZIP Indiana Alcoholic Beverage Permit Number(s) Federal Identification Number IN Taxpayer Identification Number Telephone Number Section: B Shipment Information Sold to: 1. 2. 3. 4. 5. 6. Alcohol Document Document Document Alcoholic Federal Type Type Date Number Beverage Identification Permit Number Number 7. Name 8. Address 9. Total Gallons 10. Total Wine (W) Gallons 11. Total Liquor (L) Gallons 12. Total Beer (B) Gallons 13. Total Cider (C) Gallons I hereby certify, under penalty of perjury, that the information contained herein and on supporting documents, is true, correct, and complete to the best of my knowledge and belief. Name of Business/Taxpayer: _______________________________ Email Address: __________________________ Signature of Agent or Taxpayer: _________________________________________ Mail to: Indiana Department of Revenue P.O. Box 6114 Indianapolis, IN 46206-6114 Date: ______________________ Questions related to this form: Call (317) 615-2710 Email excisetax@dor.in.gov American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Primary Source Suppliers Monthly Report What Is The ALC-PS? The ALC-PS is used to report all shipments of alcoholic beverages to wholesalers located in Indiana. Who Must File? IC 7.1-3-32.5 Primary Source of Supply The "primary source of supply" means, in regard to the alcoholic beverage being sold to a wholesaler: 1. 2. 3. 4. 5. 6. 7. 8. 9. A distiller of the alcoholic beverage; A producer of the alcoholic beverage; A vintner of the alcoholic beverage; A rectifier of the alcoholic beverage; An importer into the United States of the alcoholic beverage; An owner of the alcoholic beverage at the time it becomes a marketable product; A bottler of the alcoholic beverage; A brewer of the alcoholic beverage; or An agent specifically authorized to make sales to an Indiana wholesaler by a person listed in subdivisions (1) through (8). Physical Address ­ Indicate the actual location of your business by providing the street address, city, state, and ZIP Code. Note: A post office box is not acceptable as a business location address. Mailing Address ­ Indicate the mailing address for your business. Include the street address, post office box, city, state, and ZIP Code. Indiana Alcoholic Beverage Permit Number(s) ­ Indicate the Indiana Alcoholic Beverage Permit Number(s) obtained from the Indiana Alcohol and Tobacco Commission. Federal Identification Number ­ Indicate the nine-digit federal employer identification number (FEIN). Indiana Taxpayer Identification Number ­ Indicate the ten-digit Indiana taxpayer identification number (TID). If you do not have an Indiana TID, leave the space blank and one will be assigned to you. Telephone Number ­ Indicate the point of contact phone number for the person(s) responsible for completing this report. Include extension numbers when applicable. Section B: Shipment Information 1. Alcohol Type ­ Indicate the alcohol type being invoiced. Use W for wine, L for liquor, B for beer, and C for cider. NOTE: A liquor product with a volume of 15% or less alcohol is considered to be a wine. A fortified wine product with a volume of 21% or more of alcohol is considered to be liquor. 2. Document Type ­ Enter the appropriate code from the following list: A= Affidavit C= Confirmation CM = Credit Memo I = Invoice O = Other PO = Purchase Order 3. Document Date ­ Indicate the date of sale listed on the given document. 4. Document Number ­ Indicate the document number assigned for each sale to the wholesaler. 5. Alcoholic Beverage Permit Number ­ Indicate the Indiana Alcoholic Beverage Permit Number assigned to the wholesaler making the purchase. 6. Federal Identification Number ­ Provide the FEIN for the wholesaler making the purchase. American LegalNet, Inc. www.FormsWorkFlow.com Reporting Requirements The primary source of supply shall file a monthly report with the Indiana Department of Revenue documenting all shipments of alcoholic beverages into Indiana during the month being reported. A return must be filed even if there are no shipments made into Indiana during the reporting period. To be considered timely filed, monthly reports must be filed on or before the 10th day of the month immediately following the last day of the month being reported. If the 10th day of the month falls on a Saturday, a Sunday, a national legal holiday, or a statewide holiday, the due date is the next succeeding day that is not a Saturday, a Sunday, or such holiday. Penalty Primary source suppliers who fail to file or timely file monthly returns are subject to a penalty of $10 for each return not filed or filed after the due date of the return. Questions If you need further assistance, you can contact us at (317) 615-2710 or at excisetax@dor.in.gov. Section A: General Information Indicate the month and year for which the return is being filed in the appropriate spaces provided. Name (As It Appears on Permit) ­ Indicate the entity name as it appears on your Indiana Alcoholic Beverage Permit. 7. Name ­ Indicate the entity/business name of the wholesaler. 8. Address ­ Indicate the business address of the wholesaler making the purchase. 9. Total Gallons ­ Indicate the total gallons listed on the given document. Round gallons to two decimal places (0.00). 10. Total Wine (W) Gallons ­ Add all wine (W) quantities from the Column 9. 11. Total Liquor (L) Gallons ­ Add all liquor (L) quantities from Column 9. 12. Total Beer (B) Gallons ­ Add all beer (B) quantities from Column 9. 13. Total Cider (C) Gallons ­ Add all cider (C) quantities from Column 9. American LegalNet, Inc. www.FormsWorkFlow.com