Form Abc-281 - Statement Of Gross Receipts 1999 printable pdf download

KANSAS DEPARTMENT OF REVENUE

Alcoholic Beverage Control Division

STATEMENT OF GROSS RECEIPTS

Name of applying establishments _______________________________________________________________________________

Address ___________________________________________________________________________________________________

(Street)

(City)

(County)

Section A. (This section is to be completed if applicant was in business as a licensed food service establishment during the preceding

12-month period*.)

I HEREBY CERTIFY that the above-named establishment is a licensed food service establishment, as defined by K.S.A. 36-501,

and amendments thereto, and that during the preceding 12-month period had the following gross receipts from the sale of food* for

consumption on the premises:

YEAR

GROSS RECEIPTS

FOOD INCOME*

________ to________

$ _____________________

$ ___________________

Mo./Yr

PERCENTAGE of Gross Receipts ____________%

Section B. (This section is to be completed by all applicants.

I HEREBY CERTIFY that the above-named establishment is a licensed food service establishment, as defined by K.S.A. 36-501,

and amendments thereto, and that said establishment anticipates deriving the following estimated gross receipts from the sale of food

for consumption on the premises in the upcoming 12-month period:

YEAR

ESTIMATED GROSS RECEIPTS

FOOD INCOME*

________ to________

$ _____________________

$ ___________________

Mo./Yr

PERCENTAGE of Gross Receipts ____________%

Section C. Definitions

* “Food” means any raw, cooked or processed edible substance or ingredient, other than alcoholic liquor or cereal malt

beverage, used or intended for use or for sale, in whole or in part, for human consumption.

* “Gross Receipts”, in the case of a Drinking Establishment, Caterer or Hotel, includes all sales of food and beverages

sold on the premises. In the case of a private club, “Gross Receipts” includes sales of any type made on the licensed

private club premises. These sales include: food, alcohol, membership fees, cover charges, vending machine

concessions, video games and other sales made on the licensed premises.

* “Food Income” means the gross receipts from the sale of food on the licensed premises only. “Food Income” does not

include income derived from the sale of items mixed with alcoholic liquor or cereal malt beverage.

Section D. (ALL APPLICANTS SHALL ATTACH A TRUE COPY OF ITS PROPOSED MENU AND PRICES TO THIS FORM.)

Please use the following lines to indicate how your establishment will maintain minimum food requirements. You may attach

additional comments to this form.

I HEREBY CERTIFY that the attached menu and prices are a true and correct copy of the on-premise establishment’s menu and prices

for foods sales for the present calendar year.

PERSONAL OATH

STATE OF KANSAS

)

COUNTY OF

)

, being first duly sworn, upon deposes and says: That he or

(Print Name)

she is the authorized agent of the above-named establishment; that he or she has read the above information sheet; knows the contents

thereof and that all statements therein contained are true.

(signature of owner, partner or authorized officer)

SUBSCRIBED in my presence and sworn to before me this

day of

(Day)

(Month)

(Year)

ABC-281 (Rev. 7/99)

(Notary Public))

Form Abc-281 - Statement Of Gross Receipts 1999

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