BUREAU OF ALCOHOLIC BEVERAGES AND LOTTERY OPERATIONS Division of Liquor Licensing & Enforcement 8 State House Station, Augusta, ME 04333-0008 Phone (207) 287-4482 or (207) 287-4492 Brewer of Malt Liquor Excise Tax Report This report must be filed by the 15th of the month immediately following withdrawal from the bonded area. ________________________________________________ Name of License Holder _____________________________________________________ ______________________________________________ License Number ___________________________________________________ Name of Brewery _____________________________________________________ Current License Expires ___________________________________________________ Phone # _____________________________________________________ Month of Withdrawal ___________________________________________________ City/Town Email Address (1) Total Gallons Of Malt Liquor Withdrawn From Bond This License Year to Date (Total of Lines 2 and 3) (2) Total Gallons Of Tax Paid Malt Previously Reported To Liquor Licensing and Inspection Unit This Year (From Previous Month's Report, Line 1) (3) Total Gallons Withdrawn This Month (4) Plus Transfers In From Other Breweries (Attach Invoices) (5) Less Total Credits Claimed. (Attach Documentary Evidence to Justify Claim) (6) Less Transfers Out To Other Breweries (Attach Invoices) (1) _____________________________________ (2) _____________________________________ (3) _____________________________________ (4) _____________________________________ (5) _____________________________________ (6) _____________________________________ (7) Total Taxable Gallons This Month (Line 3 Plus Line 4, Less Lines 5 and 6) (8) Total Excise Tax Due (Multiply Line 7 X $0.35) (7) _____________________________________ (8) _____________________________________ Signed: _____________________________________________ Date:_____________________________ Printed Name: _______________________________________ Brewer Malt Liquor Excise Tax Report Rev 9-2016 American LegalNet, Inc. www.FormsWorkFlow.com