KANSAS DEPARTMENT OF REVENUE Alcoholic Beverage Control Division Topeka, Kansas 66625 ALCOHOLIC LIQUOR RECEIVED AFFIDAVIT State of ________________________ ss. County of ______________________ ___________________________________________________________________, being first duly sworn according to law, upon his oath says that he is _____________________________________ of _____________________________________________; that said (Title) (Firm) _________________________________________________ is duly licensed in the State of __________________________________ as a (Firm) distributor or a manufacturer of alcoholic liquors: That during the month of _________________________, _______, they purchased from ____________________________________ (Firm) at _______________________________________________________________ the quantities of alcoholic liquor specifically listed below: (Address) that said shipments of alcoholic liquor as itemized below were in fact transported and delivered on date designated to ___________________________________________________________ at __________________________________________________ (Firm) (Address) and that said shipments were actually received by _____________________________________________________________________ at (Firm) at __________________________________________________ for sale and consumption outside the State of Kansas. (Address) Date Invoice Number Number of Containers Size of Containers Total Wine Gallons Description Proof Affiant further swears (or affirms) that the above statement is true and correct according to original invoices and other evidence of delivery now in his presence. _________________________________________________ (Firm) By ___________________________________________________ Subscribed in my presence and sworn to before me this ___________ day of ___________________________________, ________ _________________________________________________ SEAL Notary Public My commission expires: ________________________________________ ABC-133 (Rev. 3/00) American LegalNet, Inc. www.FormsWorkflow.com Instructions for the Use of Alcoholic Liquor Received Affidavit, ABC-133 This affidavit must be prepared by any person or firm not in the State of Kansas receiving alcoholic liquor from a manufacturer in the State of Kansas. This is a monthly report and must show each purchase in detail as described in the report. If more space is needed, enclose additional sheets. This report must be prepared in duplicate; the original is due in the office not later than the 10 th day of each month. The duplicates to be retained by the purchaser. Mail to: Department of Revenue, Alcoholic Beverage Control Division, Docking State Office Building, Topeka, Kansas 66625. The report must be sworn to before a notary public in the space provided. Additional copies of the for may be secured from the manufacturer. American LegalNet, Inc. www.FormsWorkflow.com