KANSAS DISTRIBUTORS’ MONTHLY REPORT OF PURCHASES - CONTINUED Distributor Name: ____________________________________ FEIN: __________________ Month: _______________ Year: _____________ No. Product Type Code Vendor’s Kansas Supplier Permit Number or Licensed Farm Winery, Microbrewery or Manufacturer Purchase Order Received Number Purchase Order Received Date GTIN/SCC (Optional) UNIMERC Selling Units Product Unit Size Unit of Measure Received Quantity Received Unit of Measure I declare under penalties of perjury that to the best of my knowledge and belief this is a true, correct and complete return. SIGNATURE ____________________________________________ TITLE __________________________________________________ State whether individual owner, member of firm, or title if officer of corporation. ABC-218 (Rev. 7.1.11) Page ___of ___ American LegalNet, Inc. www.FormsWorkFlow.com