FORM C-230 (09/05) DISTRIBUTOR'S REPORT TABC USE ONLY Monthly Report of Beer Received ENTRY and Disposed of During the Month of: REG # SUMMARY **REPORT IS DUE ON OR BEFORE THE 15TH DAY OF THE MONTH FOLLOWING EACH REPORTING PERIOD** TRADE NAME: LICENSE NUMBER: ADDRESS: CITY: ZIP CODE: PHONE NUMBER: GALLONS (rounded off to the second decimal place) Summary of Taxes Due 1. Inventory, Beginning of Month (Line 4 on Prior Monthly Report) 2. Beer Received (Page 2, Line 1) 3. Total (Line 1 + 2) 4. Inventory, End of Month 5. Exemptions (Page 2, Line 2) 6. Total (Line 4 + 5) 7. Beer Subject to Tax (Line 3 - 6) $0.193548 8. Tax Rate Per Gallon 9. GROSS TAXES DUE $ (Line 7 x 8) 10. LESS 2% $ (If payment is received by due date) 11. LESS AUTHORIZED CREDITS $ (Attach letter of authorization) $ 12. TAXES DUE STATE AFFIRMATION, Under penalty of perjury, I swear I am an officer or an authorized representative of the above Licensee, and I have examined this report, and confirm it is true, correct, and complete. Signature Title Date INSTRUCTIONS: Prepare the report in duplicate, mail the original to the T.A.B.C., PO Box 13127, Austin, TX 78711-3127. Report must be filed on or before the 15th day of the month following each reporting period. Retain one copy for your files for a period of four years. As long as your license remains active, you must file a report even if no business was conducted. Report beer in terms of gallons rounded off to the second decimal place. For assistance, please contact the Compliance Department at (512) 2063342. PAGE 1 American LegalNet, Inc. www.FormsWorkflow.com TEXAS ALCOHOLIC BEVERAGE COMMISSION FORM C-230 (09/05) BEER RECEIVED - Schedule A (retain invoices for audit purposes) INVOICE INVOICE SUPPLIER'S CITY / GALLONS CARRIER MAKING FREIGHT BILL DATE NUMBER TRADE NAME STATE (rounded off to the second decimal place) DELIVERY NUMBER 1. TOTAL RECEIVED (To Line 2, Page 1) BEER DISPOSED OF: SALES TO TEXAS DISTRIBUTORS - Schedule B (invoices must be submitted to support each entry) SALES TO MILITARY INSTALLATIONS - Schedule C (retain invoices for audit purposes) EXPORTS OUT-OF-STATE - Schedule D (invoices must be submitted to support each entry) CARRIER CLAIMS & DESTRUCTION'S - Schedule E (documents must be provided to support each entry) 2. TOTAL EXEMPTIONS (To Line 5, Page 1) NOTE: The spaces provided above for Schedules B, C, D and E should reflect monthly totals only. If more than one entry per schedule is needed, attach a supplemental schedule(s). PAGE 2 American LegalNet, Inc. www.FormsWorkflow.com TEXAS ALCOHOLIC BEVERAGE COMMISSION SUMMARY OF BEER BRANDS AND PACKAGE SIZES SUBJECT TO TAX (sales to retailers ) TRADE NAME: LICENSE NUMBER: PACKAGE SIZES BRAND NAME (alphabetically) MONTH/YEAR: 1/2 bbl 1/4 bbl 24/12 can 24/12 btl TOTAL American LegalNet, Inc. www.FormsWorkflow.com