Department of Revenue Services
Form BT - 4 - BW
State of Connecticut
PO Box 5034
Monthly Report of
Hartford CT 06102-5034
(Rev. 02/05)
Custom Bonded Warehouses
Name of Licensed Distributor (Type or print)
Return for the Month of
Address Where Business Is Licensed
CT Tax Registration Number
City, Town, or Post Office
State
ZIP Code
FEIN
Location of Warehouse
License Number
Liquor Control Division Permit Number
This monthly report must be filed with the Commissioner of Revenue Services not later than the last day of the month
following the calendar month being reported. Attach all schedules as noted on the reporting lines below.
Distilled Liquors
Still Wines
Fortified Wines
Alcohol
not over 21% alcohol
over 21% alcohol
and
and
components for
Sparkling Wines
manufacturing
Wine Gallons
Proof Gallons
Wine Gallons
Wine Gallons
1.
Inventory in Bond at the Beginning of the Month
2.
Total of Merchandise Placed in Custom Bonded
Warehouses (Schedule BW-1) .........................
3.
Total (Add Line 1 and Line 2) ...............................
4.
Inventory in Bond at the End of the Month ...........
5.
Accountable Balance (Line 3 minus Line 4) ........
6.
Total Merchandise Withdrawn From Custom
Bonded Warehouses (Schedule BW-2) (Report
on Form BT-5, Schedule A) .............................
7.
Total Merchandise Transferred in Bond Outside
Connecticut (Schedule BW-3) ..........................
8.
Total Merchandise Transferred in Bond Inside
Connecticut (Schedule BW-4)
9.
Total Adjustment (Schedule BW-5) ....................
10. Total (Add Line 6 and Line 9) ...............................
11. Difference, if any (Line 5 minus Line 10)
Declaration: I declare under penalty of law that I have examined this report (including any accompanying schedules and statements) and, to the best of
my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return to DRS is a fine of not more than
$5,000, or imprisonment for not more than five years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of
which the preparer has any knowledge.
Taxpayer Signature
Title
Date
Print Taxpayer Name
Telephone Number
Taxpayer SSN
Paid Preparer Signature
Preparer’s Address
Preparer’s SSN or PTIN