Alcoholic Beverage Distributors Monthly Report - Wine {4000A-100-1W}

DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO 1940 NORTH MONROE STREET · TALLAHASSEE, FL 32399-1022 DBPR Form AB&T 4000A-100-1W Rev. 12/03 ALCOHOLIC BEVERAGE DISTRIBUTOR'S MONTHLY REPORT WINE IMPORT DOMESTIC Prepare in TRIPLICATE. Submit ORIGINAL and FIRST COPY to the AUDITING DISTRICT OFFICE of the DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO. SECOND COPY is to be retained by the licensee. This report and payment must be filed in accordance with the provisions of Chapter 561, Florida Statutes, on or before the tenth day of the month following the month being reported. Make remittances payable to the "Division of Alcoholic Beverages and Tobacco". Distributors paying $50,000 or more in excise taxes per year must remit tax payments through electronic funds transfer, as prescribed by Chapter 561.111, Florida Statutes. Licensee Name Address Month Reported 20 Phone No. ( City Reporting Period ) License No. FL Zip through This report is true and correct to the best of my knowledge and belief and is submitted under penalty of perjury. Typed or Printed Name COMPUTATION OF TAX 1. 2. 3. 4. a. Gallons -- under 17.259% Gallons -- 17.259% or More Gallons -- Natural Sparkling Gallons -- Apple Cider Authorized Signature @ $ 2.25 per gallon @ $ 3.00 per gallon @ $ 3.50 per gallon @ $ 0.89 per gallon $ $ $ $ Gallons of Wine Coolers (included within Line 1 Tax Calculations) 5. Gross Tax Upon Wine (Lines 1, 2, 3, & 4) 6. Breakage / Spoilage Deduction (Line 5 x .0049) 7. Subtotal (Line 5 minus line 6) 8. Less: Discount of 1.9% (Does not apply if Report or Payment is filed late) 9. Certificate of Credit (if any approved by DAB&T) 10. Net Amount Excise Tax (Line 7 minus lines 8 & 9) $ $ $ $ $ No. $ Import 40033 / Domestic 40030 DAB&T USE ONLY Report Receipt Postmark Date Delivery Date Delinquent Action In'ls Payment Verification Receipt Number Payment Date Excise Tax Paid In'ls Field Review Initial Review Date Amended Date Amended Amount In'ls Central Processing Initial Receipt Date Completed Date In'ls American LegalNet, Inc. www.FormsWorkFlow.com