SD EForm - 0886 V1 ALCOHOLIC BEVERAGE GALLONAGE REPORT OF MONTHLY SALES TO ELLSWORTH A.F.B. MILITARY MESS'S Mail To: Special Tax Division, Department of Revenue, 445 E Capitol Ave, Pierre, SD 57501-3100 Malt Beverages In barrels Dakota's Officer's Club ______________ (Month & Year) Wine & diluted bev. except spkg. 3.2 %-14% In gallons Wine except Spkg. 14-1% - 20% In gallons Wine & Sparkling wine 20.1% - 24% In gallons Other diluted bev., wines & distilled spirits In gallons Cider In gallons Billeting Base Exchange Shoppette Snack & Brew Bowling Center Recreation Center Other This report is necessary for the proper reversion of the occupational tax due Ellsworth AFB based on the monthly sales made by your firm to the units at Ellsworth Air Force Base. This report must be filed on or before the 10th of every month reflecting the previous month sales. If no sales were made during the month, a "No Sales Report" must be filed. ____________________________________________________________________________________________________ I DELARE UNDER THE PENALTY OF PERJURY THAT THIS REPORT HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS A TRUE, CORRECT AND COMPLETE REPORT. Firm Name__________________________________________________________ Date:_________________________ Signature of Preparer__________________________________________________ License Number:________________ SD SPT 106 / 04-12-2000 American LegalNet, Inc. www.FormsWorkFlow.com