en-US73A576 (06-17)en-USCommonwealth of Kentuckyen-USDEPARTMENT OF REVENUEen-USVINTNER222Sen-US WINE REPORT en-USFOR DEPARTMENT USE ONLY þ þ þ þ þ þ / þ þ / þ þ þ / þ þ þ Account Number þ Tax þ Mo. þ Yr. en-USFile with the Department of Revenue on or before the 20th of the month following the month for which the report is made.en-USIf a small farm winery, this report is due on or before the 20th of the month following the quarter for which the report is made. en-USName and Address of Vintneren-USRevenue Account Numberen-USState License Numberen-USReport for Month ofen-US, 20 en-USNumber of Cases Part I227 þ Wine Excise þ Tax Report en-US4 Gal.en-US12 Liters þ 1. þ Direct sales to Kentucky retailers þ and consumers (as shown on Form 73A530) þ. þ þ 2. þ Samples taken þ from Kentucky inventory þ. .............................. þ þ 3. þ Other þ. .............................................................. þ þ 4. þ Total subject to excise tax þ (add lines 1, 2 and 3) þ. ..................................... þ þ 5. þ Less quantities returned þ by retailers and consumers þ (complete schedule on reverse side) þ. .............. þ þ 6. þ Balance subject to excise tax þ (line 4 minus line 5) þ. ....................................... þ þ 7. þ Tax rate per case þ. ............................................ þ $ þ 2.00 þ $ þ 1.60 þ $ þ 1.50 þ $ þ 1.20 þ $ þ 1.59 þ $ þ 1.19 þ $ þ 1.19 þ $ þ 4.80 þ þ 8. þ Excise tax applicable þ (line 6 times line 7) þ. ........................................ þ þ 9. þ Miscellaneous credits and þ charges þ. ........................................................... þ $ þ $ þ $ þ $ þ $ þ $ þ $ þ $ þ 10. þ en-USTotal excise tax dueen-US (total of all items on line 8 plus or minus line 9) þ. ................................................................................... þ $ þ en-US21en-USPart II227Wine Wholesale Sales Tax Report 11. þ Gross receipts from sales of wine to Kentucky retailers and consumers (tax included) þ. .................................... þ $ þ 12. þ Receipts from sales of wine produced by small farm winery producing no more than 50,000 gallons per þ calendar year þ. ....................................................................................................................................................... þ $ þ 13. þ Net receipts (line 11 minus line 12) þ. .................................................................................................................... þ $ þ 14. þ Taxable receipts (line 13 divided by 1.1025) þ. ...................................................................................................... þ $ þ 15. þ Gross tax applicable (line 14 times .1025) þ. ......................................................................................................... þ $ þ 16. þ Collection and reporting fee (line 15 times .01) þ. ................................................................................................. þ $ þ 17. þ Net tax due (line 15 minus line 16) þ. .................................................................................................................... þ $ þ 18. þ Miscellaneous credits and charges þ. ...................................................................................................................... þ $ þ 19. þ en-USTotal wholesale sales tax dueen-US (line 17 plus or minus line 18) þ. .................................................................. þ $ þ en-US24 en-USen-USand belief, a true, correct and complete report.en-US þ þ þ þ en-US þ þ þ Signature þ Title þ Date þ þ þ en-US3.2 Gal.en-US3 Gal.en-US2.4 Gal.en-US9 Litersen-USMiniaturesen-USOtheren-US(specify)en-USen-US187 Mls.en-USIMPORTANT NOTICEen-USMake check(s) payable toen-US Kentucky State Treasurer. * þ þ * en-USTotal Gallons Produced Annually (must be included on December report)en-US American LegalNet, Inc. www.FormsWorkFlow.com 73A576 (06-17) þ Page 2 en-USSCHEDULE OF WINE RETURNEDen-USBY KENTUCKY WHOLESALERS AND RETAILERS/CONSUMERS en-USNumber of Casesen-US4 Gal.en-US12 Litersen-US3.2 Gal.en-US3 Gal.en-US2.4 Gal.en-US9 Litersen-USMiniaturesen-USOtheren-US(specify)en-USHalf-Pinten-US187 Mls. en-USDateen-USReturneden-USName of Wholesaleren-USof Retailer/Consumeren-USGross receipts from sales at wholesale or wholesale sales shall not include the following sales: þ 225 þ Sales made between wholesalers or between distributors. þ 225 þ Sales made by a small farm winery or wholesaler of wine produced by a small farm winery, if that small farm winery produces en-USen-USKRS 131.180 imposes a penalty of 2 percent of the tax, up to a maximum of 20 percent of the tax for each 30 days or fraction thereof that en-USen-USen-USen-USAdditional information may be obtained by contacting the Excise Tax Section, Department of Revenue, Station 62, P.O. Box 1303, Frankfort, en-USKentucky 40602-1303, or by calling (502) 564-6823. American LegalNet, Inc. www.FormsWorkFlow.com