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Form Liq-4b - Liquor Wholesaler Monthly Report Of Sales To Airlines - Nevada Department Of Taxation

NEVADA DEPARTMENT OF TAXATION

TID NO:

1550 COLLEGE PARKWAY, STE 115

(Enter 10 digit Taxpayer ID# followed by 3 digit location #)

CARSON CITY, NEVADA 89706

For the Month of _________________________

LIQUOR WHOLESALER MONTHLY REPORT OF SALES TO AIRLINES

Firm Name

Street

City

State

Zip Code

Excise tax credit (Line 4b on LIQ-1) for alcoholic beverages exported from the State of Nevada

(NRS 369.175)

Attach copies of all supporting invoices.

MALT BEVERAGES

ALCOHOLIC BEVERAGES

BOTTLE

KEG

GALLONS

OR CAN

DATE

NAME OF AIRLINE

14.1% to 22%

22.1% to 80%

GALLONS

.5% to 14 %

GALLONS

GALLON TOTALS:

LESS .5% FORMERLY DISCOUNTED:

TOTAL, ENTER ON LINE 4b OF TAX RETURN

The above information is true and correct to the best of my knowledge and belief.

Signed ..................................................................................

Title.......................................................................................

Date ……………………….......

LIQ-4b (05/07)

SUPPLEMENTAL PAGE TO LIQ-1

Form Liq-4b - Liquor Wholesaler Monthly Report Of Sales To Airlines - Nevada Department Of Taxation