File this report with the Virginia Department of Alcoholic Beverage Control MALT BEVERAGE WHOLESALER'S Report for The Month of A.B.C. Beer License No. Name P.O. Box 27491, Richmond, VA 23261 TAX REPORT Trading As on or before the tenth (10th) day of each COMMONWEALTH OF VIRGINIA DEPARTMENT OF Street and Number City or Town and State Zip Code ALCOHOLIC BEVERAGE CONTROL 9 Inventory at end of month (actual count) TOTAL (Item 4 less Item 5 and Item 6) Tax Exempt Sales & Military (Schedule B) Tax Exempt Sales Out of State (Schedule B) 10 11 12 13 14 .0200 24 .0265 16 oz 24 .0355 32 oz 12 .0710 40 oz 12 .0880 8 oz 24 .0265 10 oz 24 .0265 12 oz 24 .0265 12 oz 30 .0265 16 oz 24 .0355 24 oz 12 .0533 25 oz 12 .0555 1/4 Bbl 1 1.9879 1/2 Bbl 1 3.9758 1 Bbl 1 7.9515 5.16 Gal 1 1.3235 13.2 Gal 1 3.3858 Amount of Tax Due 48 (Schedule B) .0200 Tax Exempt Sales 36 12 oz BOTTLES .0200 7 oz CANS 24 7 oz Items 7 oz DRAUGHT Rate of Tax 8 TOTAL Containers per case 7 Net Taxable Quantity Sold during month (Item 7 less Items 8, 9 and 10) 6 Breakage and/or Spoilage during month S 5 TOTAL (Item 2 plus Item 3) E 4 Quantity Purchased or Received during month Schedule A S 3 Inventory at beginning of month (actual count) A 2 Container Size C 1 Wholesaler to Wholesaler month for the preceding month and attach check or money order payable to Department of Alcoholic Beverage Control for the amount of Tax Due TOTAL TAX DUE I swear (or affirm) that this report has been examined by me and, to the best A.B.C. USE ONLY of my knowledge and belief, is a true and complete report made in good faith CHK NO. for the period as stated, pursuant to the Virginia Alcoholic Beverage Control AMT Total Tax Due Act as amended. PMD Less 1% Statutory Discount (Signature)________________________________________________________ REC NO. TRAN NO. Net Tax Due County/City of _____________________________________________________ Commonwealth/State of _____________________________________________ FOR CALCULATION OF TAX DUE Total Other Page(s) $ Penalty for Late Filing and Payment Interest Sworn to and subscribed before me this ______ day of ______________ 20____ SEQ. NO Total Tax, Penalty, and Interest Due ___________________________________ (Notary Public) PROCESSED BY Adjustments (+/-) ___________________________ Commission Expiration Date FINAL TAX DUE $ $ Form No. 805-70 (Rev. 10/08) American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com Inv Date INVOICE NO. Purchased or Received From This Schedule Must be Filled OUT in Complete Detail for Each Order Purchased or Received SUPPLIER/ DISTRIBUTOR NO. 7 OZ 24 7 OZ 36 7 OZ 48 12 OZ 16 OZ BOTTLES 32 OZ 40 OZ 8 OZ 10 OZ 24 SCHEDULE A ---- BEER, ALE, PORTER AND STOUT PURCHASED OR RECEIVED 12 OZ 24 12 OZ 30 CANS Trading as Report for Month of 16 OZ 24 OZ 25 OZ 1/4 BBL 1/2 BBL 1 BBL 5.16 GAL 13.2 GAL Ref No. Page_____of______ DRAUGHT BEER A.B.C. License No. American LegalNet, Inc. www.FormsWorkflow.com INVOICE NO. SCHEDULE A TOTALS (Item 3) Inv Date Purchased or Received From SUPPLIER/ DISTRIBUTOR NO. 7 OZ 24 7 OZ 36 7 OZ 48 12 OZ 16 OZ BOTTLES 32 OZ 40 OZ SCHEDULE A ---- CONTINUED 8 OZ 10 OZ 24 12 OZ 24 12 OZ 30 CANS Trading as Report for Month of 16 OZ 24 OZ 25 OZ 1/4 BBL 1/2 BBL 1 BBL 5.16 GAL 13.2 GAL Ref No. Page_____of______ DRAUGHT BEER A.B.C. License No. American LegalNet, Inc. www.FormsWorkflow.com TOTAL (Item 10) (NAME/LICENSE NO.) WHOLESALER/WHOLESALER TOTAL (Item 9) OUT OF STATE TOTAL (Item 8) (Schedule B) Tax Exempt & Military MILITARY Name and Address of Purchaser Inv Date This Schedule Must be Filled OUT in Complete Detail for Each Tax Exempt Order INVOICE NO. 7 OZ 24 7 OZ 36 7 OZ 48 12 OZ 16 OZ BOTTLES 32 OZ 40 OZ 8 OZ SCHEDULE B ---- BEER, ALE, PORTER AND STOUT TAX EXEMPT QUANTITIES 10 OZ 24 12 OZ 24 12 OZ 30 CANS Trading as Report for Month of 16 OZ 24 OZ 25 OZ Page_____of______ 1/4 BBL 1/2 BBL 1 BBL 5.16 GAL 13.2 GAL DRAUGHT BEER A.B.C. License No.