Monthly Personal Activities Report Mail to: Department of Revenue, Division of Special Taxes, 445 East Capitol Ave, Pierre, South Dakota 57501-3100 All alcohol beverage wholesaler’s management personnel and solicitors shall file this monthly personal activities report in compliance with the provisions of consent order dated January 24, 1977. __________________________________________________________ Name __________________________________________ Dated __________________________________________________________ Address __________________________________________ License No. __________________________________________________________ City State Zip _________________________________________ Month Year All questions must be answered and any additional information applicable to any question must be noted in detail on the reverse side of this report. CODE ACTIVITY QUESTIONS Check One Yes No A Have you offered or given a kickback to any licensed retailer? (IF YES LIST) . . . . . . . . . . . . . . . . . . . . . . ________ ________ B Has any licensed retailer, their employees or agents solicited kickbacks from you? (IF YES LIST) . . . . . . ________ ________ C Have you given alcohol beverage as gifts or samples to licensed retailers or consumers? (IF YES LIST) . . ________ ________ D Have you withdrawn alcohol beverages from the wholesale house stock for any purpose? (IF YES LIST ALL RECIPIENTS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________ ________ E Do you know of any distillery, winery or importers representative who has offered or given a kickback to any S. D. licensed retailer or wholesaler? (IF YES LIST) . . . . . . . . . . . . . . . . . . . . . . . ________ F Do you know of any licensed retailer who has been invoiced for alcohol beverages that was never delivered to or received by the retailer? (IF YES LIST) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________ ________ G Have you sold any alcohol beverages to any person who was not a licensed retailer? (IF YES LIST) . . . . ________ ________ H Have you delivered any alcohol beverages other than authorized samples to any licensed retailer? (IF YES LIST) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______ ________ VERIFICATION: I hereby verify and declare, under penalties of perjury, that I have examined this report together with any attachments thereto and to the best of my knowledge and belief the report is true, correct and complete. EMPLOYED BY: _____________________________________________ NAME OF WHOLESALER ____________________________________________________ SIGNED Subscribed and sworn before me this ______________ day of ________________________ , 20_____ __________________________________________ NOTARY PUBLIC SD REV SPT 117 (08/01) American LegalNet, Inc. www.FormsWorkflow.com Page 2 Report all information related to any (YES) answer and identify the answer with the alphabetical code provided for that particular question. Answer Code Name City License Number Bottle Size American LegalNet, Inc. www.FormsWorkflow.com