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 KANSAS SUPPLIERS’ MONTHLY REPORT OF SHIPMENTS TO KANSAS DISTRIBUTORS REPORT PERIOD Month: Supplier Name Year: Kansas Supplier Permit No. 19 - 00 ___ - ___ ___ ___ ___ - ___ ___ Business Mailing Address City State Person Completing Report E-Mail Address Telephone Number FAX Number I do not have any shipments to report this month. PURCHASE ORDER NUMBER SHIPMENT DATE DISTRIBUTOR NAME Zip Code Spreadsheet attached PURCHASE ORDER NUMBER SHIPMENT DATE DISTRIBUTOR NAME This report must be filed by the 15th day of the following month. You are required to file this report even if you have no shipments to report. All records shall be maintained for three years and shall be available for inspection by the Director or any agent or employee of the Director or Secretary upon request. DO NOT SEND INVOICES. 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. DATE __________________________________________________ ABC-1003 (Rev. 7.1.11) American LegalNet, Inc. www.FormsWorkFlow.com