NEVADA DEPARTMENT OF TAXATION 1550 COLLEGE PARKWAY, STE 115 CARSON CITY, NEVADA 89706 TID: - (10 digit Taxpayer ID# and 3 digit location #) For the Month of _ LIQUOR IMPORTER/WHOLESALER MONTHLY REPORT OF LOSS ___ Firm Name: Street: City: State: Zip Code: Excise tax credit (Line 2, LIQ-1) for alcoholic beverages lost, stolen or damaged in transit or on premises. (NRS 369.370) Attach copies of all supporting loss claims which have been filed with carriers, shippers, etc. MALT BEVERAGES ALCOHOLIC BEVERAGES GALLONS .5% to 14% GALLONS 14.1% to 22% GALLONS 22.1% to 80% DATE EXPLAIN TYPE OF LOSS, SHIPPER, BRAND NAME, ETC. KEG GALLONS BOTTLE OR CAN GALLONS GALLON TOTALS: LESS .25% FORMERLY DISCOUNTED: TOTAL, ENTER ON LINE 2 OF TAX RETURN: The information above is true and correct to the best of my knowledge and belief. Signed Title Date American LegalNet, Inc. www.FormsWorkFlow.com LIQ-2 2/3/11 SUPPLEMENTAL PAGE TO LIQ-1