INDIANA DEPARTMENT OF STATE REVENUE PRIMARY SOURCE SUPPLIER’S MONTHLY REPORT Form ABP1-WL State Form 46919 (R2/ 3-09) Reporting Month Name of License Holder (as indicated on permit) Year Mailing Address City or Town ABC Permit# State Zip Code Federal ID Number GENERAL INFORMATION DEFINITIONS: I.C. 7.1-1-3-5 Alcoholic Beverage The term “alcoholic beverage” means a liquid or solid that: (1) is, or contains, one-half percent (0.5%) or more alcohol by volume; (2) is fit for human consumption; and (3) is reasonable likely, or intended, to be used as a beverage. fermentation of the natural sugar content of fruit, fruit juice, or other agricultural products containing sugar, including necessary additions to correct defects due to climatic, saccharine, and seasonal conditions, and also the alcoholic fortification of the beverage. The term does not mean an alcoholic beverage that contains twenty-one percent (21%), or more, of absolute alcohol reckoned by volume. I.C. 7.1-1-3-6 Beer The term “beer” means an alcoholic beverage contained by the fermentation of an infusion, or decoction of barley malt or other cereal and hops in water. REPORTING REQUIREMENTS The primary source of supply shall file a monthly report with the Department of Revenue documenting all shipments of alcoholic beverages into Indiana during the month being reported. A return must be filed even if there are no shipments made into Indiana during the reporting period. I.C. 7.1-1-3-18 Gallon The term “gallon” means a liquid measure containing two hundred thirty-one (231) cubic inches. The Indiana Department of Revenue requires that all necessary information be completed. (Printouts are acceptable if the required information is included.) An incomplete report may be returned for additional information. I.C. 7.1-1-3-21 Liquor The term “liquor” means an alcoholic beverage containing alcohol obtained by distillation. The term also means a wine that contains twenty-one percent (21%) , or more, of alcohol reckoned by volume. However, the term does not include industrial alcohol. To be considered timely filed, monthly returns must be filed on or before the tenth (10th) day of the month immediately following the last day of the month being reported. If the tenth day of the month falls on a Saturday, a Sunday, or a national legal holiday, or a statewide holiday, the due date is the next succeeding day that is not a Saturday, a Sunday, or such holiday. I.C. 7.1-1-3-23 Malt Articles The term “malt articles” means malt, malt syrup, malt extract, liquid malt, or wort, and their containers. Penalty I.C. 7.1-3-32.5 Primary Source of Supply The “primary source of supply” means, in regard to alcoholic beverage being sold to a wholesaler: (1) a distiller of the alcoholic beverage; (2) a producer of the alcoholic beverage; (3) a vintner of the alcoholic beverage; (4) a rectifier of the alcoholic beverage; (5) an importer into the United States of the alcoholic beverage; (6) an owner of the alcoholic beverage at the time it becomes a marketable product; (7) a bottler of the alcoholic beverage; (8) a brewer of the alcoholic beverage; or (9) an agent specifically authorized to make sales to an Indiana wholesaler by a person listed in subdivisions (1) through (8). Primary source suppliers who fail to file or timely file monthly returns are subject to a penalty of ten dollars ($10) for each return not filed or filed after the due date of the return. GENERAL INFORMATION A. Indicate the month and year for which the return is being filed in the appropriate spaces provided. B. Indicate the primary source supplier’s name, Alcoholic Beverage Commission permit number, and federal identification number. C. Indicate “page of “ in the appropriate space provided. D. Itemize each sale, by invoice, separately. Group sales by customers in order of date sold. E. When reporting gallons of beer, round gallons to the nearest hundreth (0.00) decimal place. F. Additional copies of page 2 of Form ABP1-B, Primary Source Supplier’s Monthly Report, may be submitted if needed. Each page should indicate a page number and total gallons. I.C. 7.1-1-3-46 Table Wine The term “wine” means an alcoholic beverage obtained by the I hereby declare under penalties of perjury that the information contained in this return, including accompanying schedules and statements, is true, correct and complete to the best of my knowledge and belief. INDIANA DEPARTMENT OF REVENUE P.O. BOX 6114 INDIANAPOLIS, INDIANA 46206-6114 Taxpayer or Duty Authorized Agent SIGN HERE Print or Type Name Title Business Phone (Area Code and Number) Questions related to this form call (317) 615-2710 Date American LegalNet, Inc. www.FormsWorkFlow.com INDIANA DEPARTMENT OF STATE REVENUE PRIMARY SOURCE SUPPLIER’S MONTHLY REPORT Page of Form ABP1-WL State Form 46919 (R2/ 3-09) NAME OF PERMIT HOLDER REPORTING MONTH/YEAR ABC PERMIT # FEDERAL ID# Sold To Invoice Date Invoice Number Name NOTE: Do not combine invoices. A liquor product with a volume of 15% or less alcohol is considered to be a wine. A fortified wine product with a volume 21% or more of alcohol is considered to be a liquor. Gallons Wine Address Gallons Liquor Total Gallons Questions related to this form call (317) 615-2710 American LegalNet, Inc. www.FormsWorkFlow.com