3000 PACIFIC AVE SE PO BOX 43085 OLYMPIA WA 98504-3085 E-mail: beerwinetaxes@lcb.wa.gov WASHINGTON BEER IMPORTERS SUMMARY TAX REPORT FORM LIQ-788 (Revised 07/15) License Number License Name Location Address City, State & Zip MONTH If Revised Report (check box) YEAR PART 1: PURCHASES REPORT Parts 1 and 2 are Non-Taxable (A) TOTAL BARRELS @ $8.080 (B) TOTAL BARRELS @ $4.782 (1) PART 2: (2) DISTRIBUTOR'S WSLCB LICENSE NO. BEER SALES TO WASHINGTON DISTRIBUTORS (ONE LINE PER DISTRIBUTOR FOR REPORTING MONTH) (3) SOLD TO DISTRIBUTOR'S NAME CITY (4) TOTAL BARRELS @ $8.080 (5) TOTAL BARRELS @ $4.782 TOTALS FOR PART 2 PART 3: (6) IMPORTERS REPORT OF ALL SAMPLES USED (does not include those shipped to Distributors where Distributor pays tax) (A) (B) TOTAL BARRELS @ $4.782 (Taxes are owed on Samples only) (7) Certified True and Correct Under Penalty of Perjury Signature of Person Completing Form TOTAL BARRELS @ $8.080 Box (7) Col (A) X $8.080 = (8) Box (7) Col (B) X $4.782 = (8) (8) (9) (10) (11) (12) Taxes Due Current Month PENALTIES for late reporting 2% per month of amounts on line (9) Printed Name Date Telephone No Prior Credits or Balances Due (if any) E-Mail Address TOTAL DUE After Adjustments American LegalNet, Inc. www.FormsWorkFlow.com LIQ-788 (Revised 07/15) WSLCB USE ONLY Amount Received Postmark Date