ATT – 131 (6/05) GEORGIA DEPARTMENT OF REVENUE ALCOHOL AND TOBACCO DIVISION 1800 CENTURY CENTER BLVD., N.E. ATLANTA, GEORGIA 30345 MONTHLY EXCISE TAX REPORT OF DISTILLED SPIRITS, MALT BEVERAGES AND WINES DISTRIBUTED OR SOLD IN OR OVER THE STATE OF GEORGIA BY AIRLINES AND RAILWAY PASSENGER CARRIERS For the month of , 20 NAME OF CARRIER GEORGIA LICENSE NO. STREET ADDRESS CITY STATE ZIP CODE INSTRUCTIONS This report must be filed with the Georgia Department of Revenue on or before the 15th of each calendar month covering all distilled spirits, malt beverages and wines distributed or sold in or over the State of Georgia during the preceding calendar month. This report also should be signed by an authorized agent of the company, notarized and mailed to: P.O. BOX 49728, ATLANTA, GA 30359. WINES (REPORT IN LITERS) 14% or less Alc. Over 14% Alc. COMPUTATION OF TAX DISTILLED SPIRITS (Report in Liters) MALT BEVERAGES (Report in Gallons) 1. Total purchased for use within total system for the month 2. Georgia Ratio allocation (Percentage) 3. Total distributed or sold in or over the State of Georgia during the month (Line 2 x Line 1) 4. Georgia excise tax rate $.40 per Liter $.67 per Liter $1.00 per Liter $.48perGallon 5. Tax due by each type (Line 3 x applicable tax rate shown on line 4) $ $ $ $ 6. Total excise tax due (Totals of all columns in Line 5) $ (Remit herewith) AFFIDAVIT Before me, an officer authorized by law to administer oaths, personally appeared , an authorized agent of the above named business, who, first being duly sworn, deposes and says that this report is true and correct to the best of his knowledge and belief, and is filed in accordance with the law. Subscribed and sworn to before me this day of , 20 SIGNED (Authorized Agent) NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkflow.com