DBPR Form AB&T 4000A-100-1W Rev. 12/03 DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO 1940 NORTH MONROE STREET • TALLAHASSEE, FL 32399-1022 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 Phone No. ( Address City Month Reported 20 ) License No. FL Zip Reporting Period 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 Authorized Signature COMPUTATION OF TAX 1. Gallons -- under 17.259% @ $ 2.25 per gallon $ 2. Gallons -- 17.259% or More @ $ 3.00 per gallon $ 3. Gallons -- Natural Sparkling @ $ 3.50 per gallon $ 4. Gallons -- Apple Cider @ $ 0.89 per gallon $ a. 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 No. $ (Line 7 minus lines 8 & 9) Import 40033 / Domestic 40030 DAB&T USE ONLY Report Receipt In'ls Payment Verification In'ls Field Review In'ls Central Processing Postmark Date Receipt Number Initial Review Date Initial Receipt Date Delivery Date Payment Date Amended Date Completed Date Delinquent Action Excise Tax Paid Amended Amount American LegalNet, Inc. www.FormsWorkFlow.com In'ls