Kansas Department of Revenue Alcoholic Beverage Control Division 915 S.W. Harrison Street, Room 214 Topeka, KS 66625-3512 Phone: 785-296-7015 Fax: 785-296-7185 ALCOHOLIC BEVERAGE CONTROL GALLONAGE TAX REMITTANCE VOUCHER Distributors’ EDI and Web Filers MONTH:_______________ YEAR: __________ FEIN: ___ ___ - ___ ___ ___ ___ ___ ___ ___ TODAY’S DATE: _____________________________________________________________________ DISTRIBUTOR NAME: ________________________________________________________________ LICENSE NUMBER: __________________________________________________________________ CONTACT PERSON: _________________________________________________________________ EMAIL ADDRESS: ___________________________________________________________________ I have filed my Liquor Enforcement Tax Return electronically. GALLONAGE TAX PAYMENT DISTRIBUTION PRODUCT TYPE: DEPOSIT CODE: TAX AMOUNT DUE: Alcohol and Spirits (GLAS) $ Fortified Wine (FWGL) $ Light Wine (LWGL) $ Beer (GLBR) $ Cereal Malt Beverage Flavored Malt Beverage – Strong Flavored Malt Beverage – Weak (MBTX) $ ( GFMB) $ (FMBT) $ TOTAL REMITTANCE = $ ABC 216 (Rev 7.1.11) American LegalNet, Inc. www.FormsWorkFlow.com