Form Alc36e - E Permit Holder'S Ohio Wine, Mixed Beverage And Beer Tax Return - Ohio Department Of Taxation, Ohio

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Excise Tax Form
ALC-36E Rev. 1/04
P.O. Box 530
Columbus, OH 43216-0530
E Permit Holder’s Ohio Wine, Mixed Beverage and Beer Tax Return
For the month of
20
Name
Address
City
State
ZIP
Wine and Mixed Beverage
A
B
C
D
E
Beverage Sold in
Mixed Beverage
Ohio During
14% or Less
14%-21%
Vermouth
21%-Less
Sparkling
Report Period
($.30 Per Gallon)
($.98 Per Gallon)
($1.08 Per Gallon)
($1.20 Per Gallon)
($1.48 Per Gallon)
1.Gallons and fractions
thereof
2.Tax on beverage sold
Gallons
3.Additional tax ($.02 per gallon reported on line 1
X $.02
columns A, B, C and E – do not include column D)
$
4.Total tax due on wine and mixed beverage sold
$
in Ohio
Beer and Malt Beverage
Beer
Beverage Sold in Ohio
A
B
During Report Period
12 oz. Bottles or Cans
oz. Bottles
($0.017 Per Container)
(See Pertinent Facts)
5.Total number of bottles
6.Tax on beer and malt beverage sold
7.Total tax due on beer and malt beverage sold
$
$
in Ohio
8.Total tax due (line 4 plus line 7)
$
I declare under penalties of perjury that this return (including any accompanying schedules and statements) has been exam-
ined by me and to the best of my knowledge and belief is a true, correct and complete return and report.
Signature
Title

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