Form Abc-1013 - Kansas Farm Winery 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 FARM WINERY MONTHLY GALLONAGE TAX RETURN AND SALES REPORT
MONTH:________________
YEAR:__________
FEIN: ___ ___ - ___ ___ ___ ___ ___ ___ ___
SCHEDULE A - SALES:
I have no sales to report this month.
Total Number of Bottles:
Type of Sale
375ml
750ml
1.5LT
Other
Off-Premise Licensees
On-Premise Licensees
Consumers
1
Non-Beverage User Permittees
SCHEDULE B - SAMPLES:
No samples were given this month.
Total Number of Bottles:
Tasting Samples
375ml
750ml
1.5LT
Other
Samples
SCHEDULE C - SALES TO DISTRIBUTORS:
I have no sales to Distributors to report this month.
Purchase Order
Distributor Name
Invoice Date
Invoice Number
Invoice Total
Number
$
$
$
$
2
SCHEDULE D – KANSAS SPECIAL ORDER SHIPPING LICENSE
SALES:
I do not have a Kansas Special Order Shipping license.
I have no Kansas Special Order Shipping license sales to report this month.
Customer Name
Address
Quantity
Size
Order Total
$
$
$
$
3
SCHEDULE E– KANSAS FARMERS’ MARKET SALES PERMIT
I do not have a Kansas Farmers’ Market Sales Permit.
I have no Kansas Farmers’ Market Sales Permit sales to report this month.
Date
Location
Quantity
Order Total
$
$
$
I declare under penalties of perjury that to the best of my knowledge and belief this is a true, correct and complete form.
SIGN ATURE _______________________________________ TITLE __________________________________DATE_____________
1 – Attach a copy of the Non-Beverage User Permit to your report
2 – Requires Kansas Special Order Shipping License
3 – Requires Kansas Farmers’ Market Sales Permit
ABC-1013 (Rev. 7.1.11)
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