MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL PO BOX 837 JEFFERSON CITY, MO 65102-0837 OUTSTATE SOLICITORS' MONTHLY REPORT AND TAX COMPUTATION MONTH YEAR SUBMIT IN DUPLICATE Prepare tax computation in triplicate, retain one copy for your file, submit TWO COPIES together with certified check, company check, or money order, payable to Director of Revenue for the total amount due, and Sales to Wholesale Dealers form, and copies of all invoices. To avoid penalties, this report must be postmarked to the Division of Alcohol and Tobacco Control, Jefferson City, Missouri, not later than the 15th of each month. OUTSTATE SOLICITOR'S NAME (AS LICENSED WITH MISSOURI) MISSOURI LICENSE NO. ADDRESS STATE CITY ZIP TOTAL TAXABLE SALES TO MISSOURI WHOLESALERS DURING MONTH Show Below Totals Of Taxable Sales Which Have Been Detailed On Sales To Wholesale Dealers Form. Item 1 gallons spirituous liquor @ $2.00 per wine gallon $ Item 2 gallons wine @ $ .42 per wine gallon $ Item 3 Penalty & Interest (If assessed by Division of Alcohol and Tobacco Control) Item 4 Total tax due on merchandise sold in Missouri during month, enter totals of Item 1 + Item 2 and Item 3 if applicable $ $ AFFIDAVIT I am personally familiar with the statements made in this report and swear (or affirm) that the above report, together with attached Sales to Wholesale Dealers, constitutes a true and complete record of our sales in Missouri for the month aforesaid, and that all such sales have been made in accordance with the Missouri Liquor Laws and Regulations. SIGNATURE/TITLE American LegalNet, Inc. www.FormsWorkFlow.com