Form Mb-3 - Statement Of Malt Beverages Sold To A Vermont Dealer
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1VERMONT DEPARTMENT OF TAXES
PO BOX 547
MONTPELIER, VT 05601-0547
STATEMENT OF MALT BEVERAGES SOLD TO A VERMONT DEALER
For month of __________________, 20______
File this report on or before the 20th of each month.
Distributor
Distributor’s Address
City
State
ZIP Code
VT Dealer (Use a separate sheet for each Vermont dealer.)
Address
City
State
ZIP Code
Include Transfers and/or Credits to VT Dealers
INVOICE
KEGS
CASES
TOTAL
13.2
12
12
24
24
12
24
GALLONS
Number
Date
1/2
1/4
Gals.
40 oz.
32 oz.
16 oz.
12 oz.
12 oz.
7 oz.
TOTALS
I declare, under penalties of perjury, that this return (including any accompanying schedules and statements) is true, correct, and
complete to the best of my knowledge.
Distributor Signature
Date
Prepared by (Print or Type)
Title
Form MB-3
Rev. 10/07
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