Form Abc-1025 - Microbrewery Monthly Gallonage Tax Return And Sales Report Page 4

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Kansas Department of Revenue
Alcoholic Beverage Control Division
915 S.W. Harrison Street, Room 214
Topeka, KS 66625-3512
Phone: 785-296-7015 Fax: 785-296-7185
KANSAS MICROBREWERY MONTHLY GALLONAGE TAX RETURN AND SALES REPORT
MONTH:________________
YEAR:__________
FEIN: ___ ___ - ___ ___ ___ ___ ___ ___ ___
SCHEDULE A - SALES:
I have no sales to report this month.
Type of Sale:
Total Number of Gallons:
1. Licensed Distributors (Complete Schedule B)
2. Consumers (Off-Premise Consumption)
3. Beverage Permit Holders
SCHEDULE B - SALES TO DISTRIBUTORS:
I have no sales to Distributors to report this month.
Distributor Name
Invoice Date
Invoice Number
Purchase Order Number
Invoice Total
$
$
$
$
$
$
SCHEDULE C - SAMPLES:
Tasting Samples
No samples were given this month.
Samples were given this month. Total Number of Gallons:_________________________
I declare under penalties of perjury that to the best of my knowledge and belief this is a true, correct and complete return.
SIGNATURE ____________________________________________TITLE _______________________________________
State if individual owner, member of firm, or title if officer of corporation.
Page 4 of 4
ABC-1025 (7.1.12)

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