Michigan Department of Labor & Economic Growth LIQUOR CONTROL COMMISSION 7150 Harris Drive, P.O. Box 30005 - Lansing, Michigan 48909-7505 MICHIGAN MIXED SPIRIT DRINK TAX REPORT LICENSEE NAME AND BUSINESS ADDRESS LICENSE NO. BUSINESS TELEPHONE # ( ) MONTH/YEAR INSTRUCTIONS 1. This form MUST be filed on or before the 15th DAY OF THE MONTH for the previous month whether or not any sales transactions have occurred. Licensees who fail to submit a required report or who file a false report may have their licenses suspended or revoked. 2. Enter heading information requested above. 3. Summarize sales to MICHIGAN WHOLESALERS and enter in the spaces provided below. Carry liter calculations to two places to the right of the decimal. 4. Attac h all invoices and supporting documents. 5. Calculate TAX DUE. Make check payable to the STATE OF MICHIGAN. 6. Mail this report, the invoices and the check to the above heading address. If you have further questions, please call (517) 322-1071. Pack Size Liters/Case 24/200 ML 9.6 24/375 ML 9 12/750 ML 9 12/ L 12 6/1.75 TOTAL LITERS 4.8 48/200 ML Total Cases 10.5 TOTALS Tax Calculations: Total Liters _______ x $.48 = _________________ Authorized Adjustment ____________________ Total Mixed Spirit Drink Tax Due ____________________ I declare that the information contained in this report is correct to the best of my knowledge. Signature of Authorized Agent __________________________________ -------Cashier Validation (do not write below this space) -------------------------------------------------------------------------------------------- LC-MW 891 (Rev. 03/04) AUTHORITY: MCL 436.1301 COMPLETION: Mandatory PENALTY: License Revocation The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. American LegalNet, Inc. www.FormsWorkFlow.com