SD EForm - 0889 V1 South Dakota Department of Revenue Malt Beverage Tax Report Mail To: Special Tax Division, Department of Revenue, 445 E Capitol Ave, Pierre, SD 57501 Name: _______________________________________________ License No: __________________________ Address: ______________________________________________ Month of: ___________________________ City & State: __________________________________________Phone Number: ________________________ (Zip Code) Part A 1. 2. 3. 4. 5. INVENTORY (beginning of month) INVENTORY (end of month) SALES DURING MONTH (Barrels) RECEIPTS AND IMPORTS DEDUCTIONS a. Returned to Manufacturer b. Breakage - (carrier, warehouse & delivery) c. Tax Paid Purchases 6. 7. TOTAL DEDUCTIONS Total of 5 a, b, & c NET TAXABLE BBLS. (line 4 minus line 6) Malt Beverages 31 Gallon Barrels 0 0 Part B - Tax Computation: A. B. C. D. Malt Beverage (from Line 7) 0 0.00 _____________Bbls. x $8.50 = . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_________________________________ Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$_________________________________ Penalty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$_________________________________ 0.00 Total Tax, Penalty and Interest Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_________________________________ REPORT MUST BE FILED WITH FULL PAYMENT, ON OR BEFORE THE 25TH DAY OF THE SECOND MONTH FOLLOWING THE REPORTING PERIOD I declare 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. Signature of Licensee______________________________________________________ Date ______________________________ Signature of Preparer_______________________________________________________ (If other than Licensee) _____________________________________________________________ (For Office Use) Malt Beverage No. 0086 $_______________________________________ SPT 104 (08/01) American LegalNet, Inc. www.FormsWorkFlow.com Part C Malt Beverages Received During Month Malt Beverages Date Received Invoice Number Supplier Barrels TOTALS PURCHASED FROM WHOLESALERS WITHIN THE STATE (detail for line 5c) 0 TOTALS American LegalNet, Inc. www.FormsWorkFlow.com 0