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 WHOLESALER MONTHLY REPORT OF MILITARY SALES ___ Firm Name: Street: City: State: Zip Code: Excise tax credit (Line 4a on LIQ-1) for alcoholic beverages sold to MILITARY UNITS in Nevada, who qualify as "Instrumentalities of the Armed Forces of the United States" (NRS 369.335) Attach copies of all supporting invoices. DATE NAME AND LOCATION SHIPPED TO BASE, POST, STORE, INSTALLATION MALT BEVERAGES BOTTLE KEG OR CAN GALLONS GALLONS ALCOHOLIC BEVERAGES GALLONS .5% to 14% GALLONS 14.1% to 22% GALLONS 22.1% to 80% GALLON TOTALS: LESS .25% FORMERLY DISCOUNTED: TOTAL, ENTER ON LINE 4a 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-4a 2/3/11 SUPPLEMENTAL PAGE TO LIQ-1