KANSAS DEPARTMENT OF REVENUE ALCOHOLIC BEVERAGE CONTROL DIVISION GALLONAGE TAX BEER – MICROBREWERY MONTHLY REPORT License No. _______________________ Form month of ___________________, _____ Microbrewery Name Street Address City Zip Code Complete the form in duplicate, retaining one copy for your files. Send original with check, bank draft or money order to: ALCOHOLIC BEVERAGE CONTROL DIVISION DOCKING STATE OFFFICE BUILDING 915 SW HARRISON ST TOPEKA, KS 66625 Tax Report is due by the tenth of the month for the previous month’s productions. RECORD OF TAXABLE BEER PRODUCTION BARRELS BEER TRANSFERRED FROM BREWING VATS TO HOLDING VATS TAX RATE TAX DUE $5.58 Adjustments from prior month: $_____________________ TOTAL TAX DUE: $_____________________ ¼ Bbl. ½ Bbl. ½ Gal. 12 Oz/ BEER SOLD TO DISTRIBUTORS BEER SOLD FOR OFF-PREMISE CONSUMPTION I declare, under penalty of perjury and evasion, that I am familiar with the books, papers and records of the business from which this report was prepared and that this report has been examined by me and to the best of my knowledge and belief is true, correct and complete. Signature _____________________________________ Subscribed and sworn before me this _______ day of ________________________, _____ Title _______________________________ Notary Public _________________________________ My Commission expires __________________ ABC-272 (Rev. 3/00) American LegalNet, Inc. www.FormsWorkflow.com