Form 73a525 - Monthly Report Of Distillers, Rectifiers Or Bottlers

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73A525 (11-07)

FOR DEPARTMENT USE ONLY

MONTHLY REPORT

Commonwealth of Kentucky

OF DISTILLERS, RECTIFIERS OR BOTTLERS

DEPARTMENT OF REVENUE

___ ___ / ___ ___ / ___ ___

Tax

Mo.

Yr.

File with the Department of Revenue on or before the 20th

of the month following the month for which the report is made.

Name and Address of Distiller, Rectifier or Bottler

Revenue Account Number______________________

State License Number_________________________

Report for Month of

__________________________________, 20 _____

Number of Cases

Part I—Distilled Spirits

Excise Tax Report

3 Gal.

2.4 Gal.

12 Liters

10.5 Liters

9.6 Liters

9 Liters

Other (specify)

1. Direct sales to Kentucky retailers

and consumers (per Form 73A530) ..........

2. Samples taken

from Kentucky inventory ..........................

3. Other .........................................................

4. Total subject to excise tax

(add lines 1, 2 and 3) ................................

5. Less quantities returned

by retailers and consumers

(complete schedule on reverse side) ........

6. Balance subject to excise tax

(line 4 minus line 5) .................................

7. Tax rate per case ....................................... $

5.76

$ 4.61

$ 6.09

$ 5.33

$ 4.87

$ 4.57

8. Excise tax applicable

(line 6 times line 7) ...................................

9. Miscellaneous credits and

charges ...................................................... $

10. Total excise tax due (total of all items on line 8 plus or minus line 9) ..................................................................

Part II—Distilled Spirits Wholesale Sales Tax Report

11. Gross receipts from sales of spirits to Kentucky retailers and consumers (tax included) ...........................

$ _____________________

12. Taxable receipts (line 11 divided by 1.11) ...................................................................................................

$ _____________________

13. Gross tax applicable (line 12 times .11) ......................................................................................................

$ _____________________

14. Collection and reporting fee (line 13 times .01) ..........................................................................................

$ _____________________

15. Net tax due (line 13 minus line 14) ..............................................................................................................

$ _____________________

16. Miscellaneous credits and charges ...............................................................................................................

$ _____________________

17. Total wholesale sales tax due (line 15 plus or minus line 16) ............................................................

$ _____________________

IMPORTANT NOTICE

Make check(s) payable to Kentucky State Treasurer.

I, the undersigned, a principal officer of the above-named licensee, certify that I have examined this report and it is, to the best of my

knowledge and belief, a true, correct and complete report.

_________________________________________________

_____________________________

__________________________