Form Et-81 - Application Form For Refund Of Taxes On Beer Or Malt Beverages Paid In Excess Of Legal Requirements

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Excise Tax Form
ET-81 (Rev. 3/01)
P.O. Box 530= Columbus, OH 43216-0530
Application for Refund of Taxes
on Beer or Malt Beverages Paid in Excess of Legal Requirements
Reporting Period
Account No.
For period of: _______________ , 20 ____ to ______________, 20 ____ , inclusive.
File No.
1. Name __________________________________________________________
2. Address ________________________________________________________
State File No.
City ________________________________ State __________ Zip _________
3.
If records are located at an address other than line 2, show on line 3.
4. Federal Employer Identification Number or, if none
Employer Identification Account No.
Social Security No.
assigned for reporting Federal Taxes, please enter
your Social Security Number.
c
5. Reason for Claim
Out-of-State or Military Sales (Complete Schedule A and/or B)
c
Unsaleable Product (Do not destroy until you have received approval from this department.)
c
Other _________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
6.
Beer and/or Malt Beverage
Cases
Barrels
Schedule A
Schedule B
Total
$
$
$
I declare under penalties of perjury that this return or claim (including any accom-
For Department Use Only
panying schedules and statements) has been examined by me and, to the best of
my knowledge and belief, is a true, correct and complete return and report.
Voucher No. ______________________
Claimant ________________________________________________________
Title ____________________________________________________________
Date ___________________________________________________________
Agent’s Remarks (Use reverse side for additional remarks): _________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________________
I have examined this claim and any adjustments in computation
Agent ______________________________________________
have been explained to me by the agent.
Approved (District Manager) ____________________________
Date _______________________________________________ Signed _______________________________________
Claimant Signature

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