Monthly Report of Mixed Beverage Sales per ABC Unit Reported to NC Department of Health and Human Services ________________________________ ABC BOARD Report for the month of ______________________________ Number of 50 ml bottles sold Number of 100 ml bottles sold Number of 200 ml bottles sold Number of 355 ml bottles sold Number of 375 ml bottles sold Number of 750 ml bottles sold Number of 1.00L bottles sold Number of 1.75L bottles sold $ $ $ $ $ $ $ $ 0.25 0.50 1.00 1.78 1.88 3.75 5.00 8.75 $ $ $ $ $ $ $ Total tax collected Less amount remitted to Dept of Revenue (1/2 of mixed beverage surcharge - G.S. 18B-804 (b) (8) (9) $ Less amount transmitted to Dept of Hlth and Human Services ( 5% of Mixed Beverage Tax Collected - G.S. 18B-805 (b) (3)) $ $ Amount retained for local distribution Report completed by: NAME: TITLE: Date: Mo. Day Year Mail copy to: NC DEPT OF HEALTH & HUMAN SERVICES ATTN: ANN MAY 2025 MAIL SERVICE CENTER RALEIGH, NC 276992025 MXB008, Rev. 6/11 American LegalNet, Inc. www.FormsWorkFlow.com Select Bottles Sold by Size - Press Print American LegalNet, Inc. www.FormsWorkFlow.com Key in Date for reporting period Press preview and print American LegalNet, Inc. www.FormsWorkFlow.com