Application Form For Refund Of Taxes On Beer Or Malt Beverages Paid In Excess Of Legal Requirements

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ALC 81
Rev. 3/04
P.O. Box 530
Columbus, OH
43216-0530
Application for Refund of Taxes
on Beer or Malt Beverages Paid in Excess of Legal Requirements
Reporting Period
Account No.
For period of
, 20
to
, 20
, inclusive
File No.
1. Name
State File No.
2. Address
City
State
ZIP
3.
If records are located at an address other than line 2, show on line 3e
4. Federal employer identifi cation number or, if none assigned for
Employer Identifi cation Account No.
Social Security No.
reporting federal taxes, please enter your social security number.
5. Reason for claim
  Out-of-state or military sales (complete Schedule A and/or B)
 Unsaleable product (do not destroy until you have received approval from this department)
 Other
6.
Beer and/or Malt Beverage
Barrels
Cases
Schedule A
Schedule B
Total
$
$
$
I declare under penalties of perjury that this return or claim (including any accompanying
For Department Use Only
schedules and statements) has been examined by me and, to the best of my knowledge
and belief, is a true, correct and complete return and report.
Voucher no.
Claimant
Title
Date
Agent’s remarks (Use reverse side for additional remarks):
Agent
I have examined this claim and any adjustments in computa-
tion have been explained to me by the agent.
Approved (district manager)
Date
Signed
Claimant signature

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