Form Ltd 04 - Report Of Shipments Of Alcoholic Beverages Into Nevada

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REPORT OF SHIPMENTS OF ALCOHOLIC BEVERAGES INTO NEVADA
Page ____________ of ____________
TO:
Nevada Department of Taxation
Today’s date
1550 E. College Parkway Rm. 115
Carson City, Nevada 89706
Shipments for
(Month/Year)
FROM:
Certificate of
Compliance Number
(Supplier’s Name)
(Address)
(City)
(State)
(Zip)
SUBJECT:
Alcoholic beverages shipped into Nevada pursuant to Certificate of Compliance (NRS 369.430).
This form must be mailed to the Department no sooner than the end of the month and no later than
th
the 10
of the following month.
ZERO (NO SHIPMENT REPORTS) ARE NOT REQUIRED.
Nevada Import/Wholesaler Shipped To:
(One Import/Wholesaler Location per Report)
Address Shipped To:
BEER GALLONS
ALCOHOLIC BEVERAGES
SHIPPING
INVOICE
TOTAL
Keg or
Bottled or
.5% to 14%
14.1% to 22%
22.1% to 80%
DATE
NUMBER
CASES
Draught
Canned
GALLONS
GALLONS
GALLONS
TOTALS:
INCLUDE COPIES OF ALL INVOICES WITH EACH REPORT SUBMITTED.
DO NOT USE STAPLES
Reported by
Title or Department
Phone Number (
)
LTD 04
8/03

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