FORM C-210 (08/05) WHOLESALER'S REPORT TABC USE ONLY Monthly Report of Wine and Distilled Spirits Received and Disposed of ENTRY During the Month/Year of: REG # **REPORT IS DUE ON OR BEFORE THE 15TH DAY OF THE MONTH FOLLOWING EACH REPORTING PERIOD** TRADE NAME: PERMIT NUMBER: SUMMARY ADDRESS: CITY: ZIP CODE: PHONE NUMBER: GALLONS SUMMARY OF TAXES DUE DISTILLED SPIRITS WINE 14% AND LESS UNITS WINE OVER 14% - 24% SPARKLING WINE MINIATURES 1. INVENTORY, BEGINNING OF MONTH (From Line 4 on Prior Monthly Report) 2. LIQUOR RECEIVED (From Line 1, Page 2) 3. TOTAL (Line 1 + 2) 4. INVENTORY, END OF MONTH 5. EXEMPTIONS (From Line 2, Page 2) 6. TOTAL (Line 4 + 5) 7. LIQUOR SUBJECT TO TAX (Line 3 - 6) 8. TAX RATES $2.40 $0.204 $0.408 $0.516 $0.05 9. AMOUNT OF TAXES $ $ $ $ $ (Line 7 x 8) AFFIRMATION, Under penalty of perjury, I swear I am an officer or authorized representative of the above Permittee, and I have examined this report, and confirm it is true, correct, and complete. TABC USE ONLY The following box must be checked if the Permittee did not purchase, GROSS TAXES DUE sell, or possess Malt Liquor. Otherwise, Form C-233 must be filed. $ (Total of Line 9) LESS 2% $ (If payment is received by due date) Signature Title Date LESS AUTHORIZED CREDIT $ INSTRUCTIONS: Prepare the report in duplicate, mail the original to the T.A.B.C., PO Box 13127, Austin, TX 78711- (Attach letter of authorization) 3127. Report must be filed on or before the 15th of day following each reporting period. 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 though no TAXES DUE STATE $ business was conducted. For assistance, please contact the Compliance Department at (512) 206-3342. PAGE 1 American LegalNet, Inc. www.FormsWorkflow.com FORM C-210 (08/05) LIQUOR RECEIVED - Schedule A GALLONS UNITS INVOICE INVOICE SUPPLIER'S CITY TOTAL DISTILLED WINE 14% WINE OVER SPARKLING DATE NUMBER TRADE NAME STATE CASES SPIRITS AND LESS 14% - 24% WINE CARRIER MAKING MINIATURES FREIGHT BILL DELIVERY NUMBER 1. TOTAL RECEIVED (To Line 2, Page 1) LIQUOR DISPOSED OF: SALES TO TEXAS WHOLESALERS - 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 AND OTHER ALLOWABLE EXEMPTIONS - Schedule E(Documentation must be submitted 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 FORM C-210 (08/05) TRADE NAME: FORM C-210 SUPPLEMENTAL SCHEDULE: A B C D E (circle one) GALLONS UNITS INVOICE INVOICE VENDOR'S CITY TOTAL DISTILLED WINE 14% WINE OVER SPARKLING DATE NUMBER TRADE NAME STATE CASES SPIRITS AND LESS 14% - 24% WINE TOTAL CARRIER MAKING MINIATURES FREIGHT BILL DELIVERY NUMBER American LegalNet, Inc. www.FormsWorkflow.com