FORM C-214 (01/11) INDUSTRIAL ALCOHOL REPORT TABC USE ONLY ENTRY Monthly Report of Alcohol Produced, Used or Possessed for the Purpose of Use for Industrial, Medicinal, Mechanical or Scientific Purposes During the Month/Year of: SUMMARY TRADE NAME: I/LI PERMIT NUMBER: SCHEDULE A SCHEDULE B ADDRESS: CITY: ZIP CODE: PHONE NUMBER: Summary - Do Not Include Denatured Alcohol Gallons 1. Inventory, Beginning of Month (Line 5 of Prior Monthly Report) 2. Alcohol Received (Schedule A) 3. Alcohol Produced 4. Total Gallons (Lines 1,2,3) 5. Inventory, End of Month 6. Alcohol Used 7. Alcohol Shipped (Schedule B) 8. Total Gallons (Lines 5,6,7) 9. Alcohol Unaccounted For (Line 4 - 8) - attach explanation Industrial Alcohol used for the following purposes: 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 any attachments 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 or submit electronically to the e-mail address below. 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. Page 1 American LegalNet, Inc. www.FormsWorkFlow.com FORM C-214 (01/11) ALCOHOL RECEIVED - Schedule A INVOICE DATE INVOICE NUMBER (Retain invoices for audit purposes) COMPANY NAME CITY STATE GALLONS TOTAL GALLONS RECEIVED (To Line 2, Page 1) ALCOHOL SHIPPED - Schedule B INVOICE DATE INVOICE NUMBER (Retain invoices for audit purposes) COMPANY NAME CITY STATE GALLONS TOTAL GALLONS SHIPPED (To Line 7, Page 1) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com