(From Line 4 on Prior Monthly Report) (From Line 1, Page 2) (Line 1 + 2) (From Line 2, Page 2) (Line 4 + 5) (Line 3 - 6) (Line 7 x 8) SignatureE-MailTitleDate$ GROSS TAXES DUE LESS 2% LESS AUTHORIZED CREDIT TAXES DUE STATE (Total of Line 9) (If payment is received by due date) $$ (Attach letter of authorization) 7. LIQUOR SUBJECT TO TAX 9. AMOUNT OF TAXES 5. EXEMPTIONS 6. TOTAL PAGE 1 ThefollowingboxmustbecheckedifthePermitteedidnotpurchase,sell, or possess Malt Liquor. Otherwise, Form C-233 must be filed. $0.408$0.516$$$0.05$$$ AFFIRMATION,Underpenaltyofperjury,IswearIamanofficerorauthorizedrepresentativeoftheabovePermittee,andIhave examined this report, and confirm it is true, correct, and complete. 1. INVENTORY, BEGINNING OF MONTH 2. LIQUOR RECEIVED $2.40$0.204 3. TOTAL 4. INVENTORY, END OF MONTH 8. TAX RATES SPIRITS AND LESS 14% - 24% WINE SUMMARY OF TAXES DUE FORM C-210 (01/19) TABC USE ONLY INSTRUCTIONS:Preparethereportinduplicate,mailtheoriginaltotheT.A.B.C.,POBox13127,Austin,TX78711-3127. Reportmustbefiledonorbeforethe15thofdayfollowingeachreportingperiod.Retainonecopyforyourfilesforaperiodoffouryears.Aslongasyourpermitremainsactive,youmustfileareporteventhoughnobusinesswas conducted. For assistance, please contact the Excise Tax Department at (512) 206-3342 or excise.tax@tabc.texas.gov . ENTRY TABC USE ONLY SUMMARY WINE 14% WINE OVER SPARKLING $ GALLONS MINIATURES DISTILLED TEXAS WHOLESALER REPORT Monthly Report of Wine and Distilled Spirits Reporting Period: **REPORT IS DUE ON OR BEFORE THE 15TH DAY OF THE MONTH FOLLOWING EACH REPORTING PERIOD** TRADE NAME: DISTILLED SPIRITS ZIP CODE: PHONE NUMBER: PERMIT NUMBER: UNITS ADDRESS: CITY: REG # American LegalNet, Inc. www.FormsWorkFlow.com FORM C-210 (01/19) UNITSINVOICEINVOICE SUPPLIER'S CITYDISTILLEDWINE 14%WINE OVERSPARKLINGCARRIER MAKINGDATENUMBERTRADE NAME STATESPIRITSAND LESS14% - 24%WINEMINIATURESDELIVERY GALLONS LIQUOR RECEIVED - Schedule A SALES TO TEXAS WHOLESALERS AND INDUSTRIAL PERMITTEES - Schedule B SALES TO MILITARY INSTALLATIONS - Schedule C EXPORTS OUT-OF-STATE - Schedule D CASES 1. TOTAL RECEIVED (To Line 2, Page 1) LIQUOR DISPOSED OF: (invoices must be submitted to support each entry) PAGE 2 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). (retain invoices for audit purposes) (documentation must be submitted to support each entry) CARRIER CLAIMS AND DESTRUCTIONS - Schedule E (retain invoices for audit purposes) American LegalNet, Inc. www.FormsWorkFlow.com FORM C-210 (01/19) UNITSINVOICEINVOICE SUPPLIER'S CITY DISTILLEDWINE 14%WINE OVERSPARKLING CARRIER MAKINGDATENUMBER TRADE NAME STATESPIRITSAND LESS14% - 24%WINEMINIATURESDELIVERY GALLONS TRADE NAME: A B C D E (circle one) FORM C-210 SUPPLEMENTAL SCHEDULE: CASES American LegalNet, Inc. www.FormsWorkFlow.com