NEBRASKA LIQUOR CONTROL COMMISSION Form 35-7140 DIRECT SHIPPER TAX RETURN BEER, SPIRITS, AND WINE Shipper Name: _____________________________________________________________________________ Address: __________________________________________________________________________________ License Number: _____________________________ Contact Name: ________________________________ Tax Period Beginning: __________________ 20 _______ Ending _______________ 20 _____ (Taxes Due include Sales from January 1 through December 31 of each year) 1 TOTAL GALLONS SOLD TO CONSUMERS(4 decimals) DOCUMENTATION REQUIRED­SEE #8 ON INSTRUCTIONS BEER SPIRITS WINE 2 TAX RATE PER GALLONS FOR EACH CLASS 3 TOTAL AMOUNT OF TAX DUE ON EACH CLASS Line 1 x Line 2 4 5 6 GROSS TAX DUE ON ALL CLASSES Total of Line 3 Across LESS 1% DISCOUNT 1% (.01) X Line 4 X .31 $ X 3.75 $ X .95 $ $ _______________________ ________________________ NET TAX DUE (ROUND TO NEAREST DOLLAR) Line 4 minus Line 5 $ ______________________ I hereby swear that the foregoing is true and correct to the best of my knowledge as shown by our records for the Year 20 ________ . ________________________________________ Signature (Type your full name as valid signature) ___________________________________________ Telephone # ____________________________ Email address ____________________________________ FILE THIS RETURN & REMIT TAXES BY A CHECK TO THE NE LIQUOR CONTROL COMMISSION, 301 CENTENNIAL MALL SOUTH, PO BOX 95046, LINCOLN NE 68509. This form and taxes must be filed and paid (by check) on or before the 25th of January. Questions? Call (402) 471-2571. Email nlcc.spiritwinedesk@nebraska.gov. For further information, browse our web page at lcc.ne.gov. Forms and instructions are under the "Revenue" tab. Form 35-7140 Rev 4/2013 INSTRUCTIONS: Once completed, please print the form, mail, fax, or scan & email to the Nebraska Liquor Control Commission. PO Box 95046, Lincoln, NE 68509-5046 | Fax: 402-471-2814 | nlcc.spiritwinedesk@nebraska.gov American LegalNet, Inc. www.FormsWorkFlow.com