FORM C-216 (01/11) AIRLINE AND PASSENGER TRAIN REPORT TABC USE ONLY Monthly Report of Excise Taxes and Service Fees Due During the Month/Year of: ENTRY CHECKED TRADE NAME: PERMIT NUMBER: ADDRESS: CITY: ZIP CODE: PHONE NUMBER: Gallons Units Distilled Wine Over Wine Ale & Malt Spirits Excise Tax - Part 1 Wine 14% and Less 14% - 24% Sparkling Liquor Beer Miniatures 1. Gallons or Units Served in Texas 2. Tax Rate $2.40 $0.204 $0.408 $0.516 $0.198 $0.1935 $0.05 3. Excise Tax Due (Line 1 x 2) $ $ $ $ $ $ $ Excise Tax Due State (Total Line 3) $ Service Fee - Part 2 4. Gallons or Units Served in Texas 5. Services Per Gallon 6. Taxable Services (Line 4 x 5) 7. Service Fee Rate $0.05 $0.05 $0.05 $0.05 $0.05 $0.05 $0.05 8. Service Fee Due (Line 6 x 7) $ $ $ $ $ $ $ Service Fee Due State (Total Line 8) $ AFFIRMATION, Under penalty of perjury, I swear I am an officer or an authorized representative of the above Permittee, and I have examined this report, and confirm it is true, correct, and complete. Signature E-Mail Address Title Date INSTRUCTIONS: This form and tax payment must be filed on or before the 15th day of each month, following each reporting period. Mail to TABC, PO BOX 13127, AUSTIN, TX 78711-3127. Retain one copy for your files for a period of four years. As long as your permit remains active, you must file a report even if no business was conducted. For assistance, please contact the Tax Division at (512) 206-3342 or excise.tax@tabc.state.tx.us. (OVER) American LegalNet, Inc. www.FormsWorkFlow.com FORM C-216 (01/11) EXCISE TAX REFUND: The holder of an Airline Beverage Permit may apply to the Commission for a refund of the excise tax on any alcoholic beverage purchased in Texas and on which the State Excise Tax has been paid. The refund claim shall contain: A. An affidavit containing the following information for purchases from suppliers within this state: 1. Total number of containers purchased during the month by the seller, type of beverage and size of container. 2. Total gallonage of all such purchases. 3. Total excise taxes upon all such purchases. 4. A statement outlining that all such purchases will be shipped out of Texas unless sold or served by the permittee in Texas and that if such purchases are sold or served in Texas the applicable excise taxes will be reported and paid on or before the 15th day of next succeeding month. B. Submit with each claim a single copy of each seller's invoice covering any alcoholic beverages described in the affidavit. C. Any claim to be considered by the Commission must be filed by the Airline Beverage Permittee not late than one hundred twenty (120) days after the date of the earliest purchase date on the claim. D. Each claim submitted must include only purchases for one (1) calendar month. American LegalNet, Inc. www.FormsWorkFlow.com