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 SALES TO AIRLINES ___ Firm Name: Street: City: State: Zip Code: Excise tax credit (Line 4b on LIQ-1) for alcoholic beverages exported from the State of Nevada (NRS 369.175) Attach copies of all supporting invoices. MALT BEVERAGES ALCOHOLIC BEVERAGES GALLONS .5% to 14 % GALLONS 14.1% to 22% GALLONS 22.1% to 80% KEG GALLONS BOTTLE OR CAN GALLONS DATE NAME OF AIRLINE GALLON TOTALS: LESS .25% FORMERLY DISCOUNTED: TOTAL, ENTER ON LINE 4b 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-4b 2/3/11 SUPPLEMENTAL PAGE TO LIQ-1