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 Winery � Table Wine 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 Winery ________________________________________________ Current License Expires __________________________________________________ Phone # ________________________________________________ Month of Withdrawal __________________________________________________ City/Town Email Address (1) Total Gallons Of Table Wine Withdrawn From Bond This License Year to Date (Total of Lines 2 and 3) (2) Total Gallons Of Tax Paid Table Wine Previously Reported To Liquor Licensing and Inspection Unit This Year (From Previous Month's Report, Line 1) (1) _____________________________________ (2) _____________________________________ (3) Total Gallons Withdrawn This Month (4) Less Total Credits Claimed (Attach Documentary Evidence to Justify Claim) (5) Total Taxable Gallons This Month (Line 3 less Line 4) (6) Total Excise Tax Due (Multiply Line 5 X $0.60) (3) _____________________________________ (4) _____________________________________ (5) _____________________________________ (6) _____________________________________ Signed: _____________________________________________ Date:_____________________________ Printed Name: _______________________________________ Table Wine Excise Report Rev. 9-2016 American LegalNet, Inc. www.FormsWorkFlow.com