KANSAS DEPARTMENT OF REVENUE KANSAS MISCELLANEOUS TAX 915 SW HARRISON TOPEKA, KANSAS 66625-5000 DIRECT WINE SHIPMENT - ENFORCEMENT TAX RETURN VOUCHER Retail Liquor Store MONTH:___________________ FEIN: ___ ___ - ___ ___ ___ ___ ___ ___ ___ YEAR: ____________________ LICENSE: 01-___ ___ ___ - ___ ___ ___ ___ - ___ ___ RETAIL LIQUOR STORE NAME: _________________________________________________ ADDRESS: ___________________________________________________________________ CITY/STATE: ___________________________________________ ZIP CODE: ____________ CONTACT PERSON: ___________________________________________________________ E-MAIL ADDRESS:_____________________________________________________________ I have filed my Liquor Enforcement Tax Return electronically. LIQUOR ENFORCEMENT TAX PAYMENT DISTRIBUTION DEPOSIT CODE: (WETX) TOTAL REMITTANCE: $ ABC-186 (7.1.06) American LegalNet, Inc. www.FormsWorkflow.com