3000 PACIFIC AVE SE PO BOX 43085 OLYMPIA, WA 98504-3085 E-mail: beerwinetaxes@liq.wa.gov BEER AUTHORIZED REPRESENTATIVE CERTIFICATE OF APPROVAL HOLDERS SUMMARY TAX REPORT FORM LIQ-319 Licensee Number (Revised 06/10) REPORTING MONTH Licensee Name Location Address YEAR City, State & Zip NO DOMESTIC SHIPMENTS applicable NO FOREIGN SHIPMENTS PART 1: NON-TAXABLE (List by Washington Distributor and/or Importer) Check if If Correction Report (check box) Current licensee lists are available at WSLCB website: http://www.liq.wa.gov/publications/WineandBeer.aspx (2) (1) WSLCB LICENSE NO. (3) (5) (4) (F) Foreign SOLD TO: DISTRIBUTOR OR IMPORTER'S NAME TOTAL BARRELS SHIPPED (D) Domestic CITY Total Barrels from all other pages (If multiple pages used) TOTAL BARRELS THIS PAGE PLUS TOTAL FROM LINE 6 PART 2: TAXABLE (6) (7) TOTAL SAMPLE BARRELS (SAMPLES SHIPPED TO RETAILERS AND DONATIONS TO NON-PROFITS) Certified True and Correct Under Penalty of Perjury Signature of Person Completing Form (8) Line (8) X $23.580 = (9) Taxes Due Current Month (9) PENALTIES for late reporting 2% per month of the amount on line (9) Telephone No. DATE: E-Mail (10) Prior Credit or Balance Due (11) TOTAL DUE Printed Name (12) WSLCB USE ONLY WSLCB USE ONLY Payee Number Amount Received Refund Amount Postmark Date LIQ-319-20 Revised 06/10 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing LIQ-319 BEER AUTHORIZED REPRESENTATIVE CERTIFICATE OF APPROVAL HOLDERS SUMMARY TAX REPORT This report must be completed by all Beer Authorized Representative Certificate of Approval Holders each month and postmarked on or before the 20th of the following month. When the 20th falls on a Saturday, Sunday, or a legal holiday, the filing must be postmarked by the U.S.Postal Service no later than the next postal business day. A report must be filed EVERY MONTH, including months when there is no activity. Report all shipments in the month regardless of invoice date. DO NOT REPORT SALES DELIVERED TO: WSLCB, Military Installations, Commercial Carriers, or Ships Chandlers. Correction report (check box): Include changes only (additions or subtractions) that need to be made to the original report. Licensee Number: Licensee Name: Location Address: City, State, Zip: Enter your Washington State Liquor Control Board (WSLCB) 6 digit licensee number. Trade Name per license number entered. Location address per license number entered. City, State and Zip Code per license number entered. MONTH: YEAR: Enter report month (month when the beer was shipped into WA). Enter report year. NOTE: DO NOT DUPLICATE REPORTING OF THE REPRESENTED PRODUCT ON ANY OTHER FORMS; example Form LIQ-308 NO DIRECT SHIPMENTS TO A WASHINGTON CONSUMER OR RETAILER ARE ALLOWED WITH THIS PRIVILEGE Please complete the numbered fields as follows: (round to two decimal places) If you are licensed for domestic and/or foreign shipments and you have no shipments for the month, make sure that you check the appropriate box for no shipments. Part 1 (1) (2) (3) (4) (5) (6) (7) NON-TAXABLE SHIPMENTS Enter the 6-digit WSLCB license number of receiving distributor or importer in Washington State. Licensee Lists and Forms may be found on the website at: http://www.liq.wa.gov/publications/WineandBeer.aspx Enter the trade name of receiving distributor or importer in Washington State. Enter the city location of the distributor / importer. For product shipped to the distributor or importer enter: • D or Domestic for beer produced in the United States • F or Foreign for beer produced outside of the country • Use ONE line per distributor or importer for Domestic product shipped • Use ONE line per distributor or importer for Foreign product shipped Enter the total barrels shipped. (Barrel = 31 gallons) Enter total barrels from all other pages if multiple pages are needed. Enter total barrels from this page plus total from line 6. Samples shipped to Washington Beer Distributors or Beer Importers for their use include in PART 1. Part 2 (8) (9) (10) (11) (12) TAXABLE SHIPMENTS Part 2 report beer samples that are shipped to Washington retailers, donations to non-profit organizations 501(c)(3) or (6), and your licensed agent. Do not report samples provided to your appointed distributor or importer in this section. Enter the total barrels of beer samples shipped into Washington State for the month. Calculate line 8 multiplied by $23.58 (All Authorized Representative COA's tax rate per barrel). Enter the amount of penalties if reporting late. (Reports are due the 20th of the following month and penalties accumulate at 2% PER month of the total tax due on line 9). Enter the amount of an existing credit as a negative number. Indicate a balance due as a positive number. Enter the total due from entries in box 9, 10, and 11. Certified True and Correct Under Penalty of Perjury Signature of person completing the form. Entered printed name of person who completed the form. Enter the date that form is completed. Enter the telephone number of person who completed the form. Enter the e-mail address of person who completed the form. LIQ-319 (Revised 06/10) American LegalNet, Inc. www.FormsWorkFlow.com