REV-1014 (03-14) BUREAU OF BUSINESS TRUST FUND TAXES MISCELLANEOUS TAX SECTION PO BOX 280909 HARRISBURG PA 17128-0909 Print or Type BUSINESS NAME DISTRIBUTOR'S MONTHLY REPORT MALT BEVERAGE PURCHASED, SOLD AND WITHDRAWN INVENTORIES DATE ACCOUNT ID FEDERAL EIN LID NUMBER LCB LICENSE NUMBER REPORTING MONTH/YEAR INSTRUCTIONS: 1. This report and its schedules are due on or before the 15th day after the end of the month for which it is prepared. 2. Type or print figures legibly. Only use black ink when completing reports. Do not use colored ink or pencil. 3. Mail report and schedules to PA DEPARTMENT OF REVENUE, PO BOX 280909, HARRISBURG PA 17128-0909, send electronically to ra-btftmaltbev@pa.gov or fax to 717-705-8413. DESCRIPTION 1/2 PT. Can & Bottle 7 oz.-8 oz. 1 QT. Can 1 PT. Can & Bottle Other & Bottle 8.1 oz.-16 oz. 16.1 oz.-32 oz. 1/8 Barrel 1/6 Barrel 1/4 Barrel 1/2 Barrel Other 3 Liter 5 Liter 5.7 Liter Other 1. Reporting Month, Beginning Inventory 2. Purchased from Pennsylvania Manufacturers (REV-1014A, Schedule A) 3. Purchased from Importing Distributors (REV-1014B, Schedule B) 4. Purchased from Out-of-State Manufacturers (REV-1055, Schedule C) 5. Total (Add Lines 1, 2, 3 & 4) 6. Reporting Month, Ending Inventory 7. Balance to Account For (Line 5 minus Line 6) 8. Sales of Malt Beverage 9. Other Removals (Attach Explanation) 10. Total Accounted For (Add Lines 8 & 9) This Total must equal Line 7. I hereby affirm under penalties prescribed by law that this report, including accompanying schedules, has been examined by me and to the best of my knowledge and belief is a true, correct and complete report. NAME OF OWNER OR OFFICER TITLE SIGNATURE NAME OF CORPORATION OR REGISTERED TRADE NAME WITH LIQUOR CONTROL BOARD American LegalNet, Inc. www.FormsWorkFlow.com