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 REPORT OF ALCOHOLIC LIQUOR RECEIVED FROM KANSAS MANUFACTURER INSTRUCTIONS WHO MUST COMPLETE THIS FORM? This form must be completed by any person or firm not located in the State of Kansas who receives alcoholic liquor from a licensed Kansas manufacturer. WHEN IS THE FORM DUE? The completed form is due by the 15th of the month following receipt of alcoholic liquor from a Kansas manufacturer. INSTRUCTIONS TO COMPLETE THE REPORT OF ALCOHOLIC LIQUOR RECEIVED FROM KANSAS MANUFACTURER: 1. PURCHASER INFORMATION. Complete the requested information. 2. Enter the report period month and report year. 3. SPREADSHEET ATTACHED. Check this box only if you elect to attach a spreadsheet to the form. The spreadsheet must contain identical column headings to the form. 4. ALCOHOLIC LIQUOR RECEIVED FROM A KANSAS MANUFACTURER. Complete the information requested. a. SHIPMENT DATE. Enter the date shipped from your invoice. b. PURCHASE ORDER NUMBER. Enter the purchase order number from your invoice. c. NUMBER OF GALLONS. Enter the number of wine gallons that you received from the Kansas manufacturer. DO NOT report proof gallons. d. KANSAS MANUFACTURER’S LICENSE NUMBER. Enter the license number for the manufacturer you are purchasing alcoholic liquor from. You may obtain the license number from our Active Liquor Licensee database on our website at: https://www.kdor.org/abc/licensee/Search.aspx e. KANSAS MANUFACTURER’S DBA NAME. Enter the name of the Kansas manufacture from whom you are purchasing from. 5. Sign the form. Enter your title and the date you signed the form. 6. Retain a copy for your records. 7. Submit the completed original form to the address on the form by the due date. CONTACT INFORMATION: Questions may be directed to the ABC Marketing Unit. Phone: 785-296-7015 Email: ABC.Marketing.Unit@kdor.ks.gov ABC-274 (Rev. 7.1.11) American LegalNet, Inc. www.FormsWorkFlow.com 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 REPORT OF ALCOHOLIC LIQUOR RECEIVED FROM KANSAS MANUFACTURER PURCHASER INFORMATION Purchaser DBA Name Business Mailing Address City State Person Completing Report E-Mail Address Telephone Number FAX Number Report Period Month: Zip Code Year: Spreadsheet attached ALCOHOLIC LIQUOR RECEIVED FROM KANSAS MANUFACTURER SHIPMENT DATE PURCHASE ORDER NUMBER NUMBER OF GALLONS KANSAS MANUFACTURER’S LICENSE NUMBER KANSAS MANUFACTURER’S DBA NAME This report must be filed by the 15th day of the following month. 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-274 (Rev. 7.1.11) American LegalNet, Inc. www.FormsWorkFlow.com