SD EForm - 2403 V1 South Dakota Artisan Distiller Excise Tax Report Month: ___________________ (report period is one calendar month) Total Amount Remitted: _______________________ Licensee Name: ___________________________________ Address: ________________________________________ City : _________________________________ License Number: ____________ Phone Number: ______________ Part A - List Total Gallons Produced 1. Gallons manufactured or produced: __________________________ 2. Deductions: a. Breakage: ___________________________________ b. Other (specify): ___________________________________ 3. Taxable Gallons: (Line 1 minus Lines 2a & 2b) 0 ___________________________________ Part B - Tax Computation Total Tax Due 0 $_____________ Signature of Licensee or Preparer ___________________________________________ Send report and payment to: South Dakota Department of Revenue, Remit Center, Box 5055, Sioux Falls, SD 57117-5055 Report due on or before the 25th of the second month following the close of the reporting period. If no distilled spirit is produced then a zero report is due. American LegalNet, Inc. www.FormsWorkFlow.com