Sd Eform 0888 - Monthly Personal Activities Report

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SD EForm - 0888

Monthly Personal Activities Report

Mail to: Department of Revenue, Division of Special Taxes, 445 East Capitol Ave, Pierre, South Dakota 57501-3100

All alcohol beverage wholesaler’s management personnel and solicitors shall file this monthly personal activities report in compliance with

the provisions of consent order dated January 24, 1977.

__________________________________________________________

__________________________________________

Name

Dated

__________________________________________________________

__________________________________________

Address

License No.

__________________________________________________________

_________________________________________

City

State

Zip

Month

Year

All questions must be answered and any additional information applicable to any question must be noted in detail on the reverse side

of this report.

CODE

ACTIVITY QUESTIONS

Check One

Yes

Have you offered or given a kickback to any licensed retailer? (IF YES LIST) . . . . . . . . . . . . . . . . . . . . . . ________ ________

Has any licensed retailer, their employees or agents solicited kickbacks from you? (IF YES LIST) . . . . . . ________ ________

Have you given alcohol beverage as gifts or samples to licensed retailers or consumers? (IF YES LIST) . . ________ ________

Have you withdrawn alcohol beverages from the wholesale house stock for any purpose?

(IF YES LIST ALL RECIPIENTS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________ ________

Do you know of any distillery, winery or importers representative who has offered or

given a kickback to any S. D. licensed retailer or wholesaler? (IF YES LIST) . . . . . . . . . . . . . . . . . . . . . . . ________

Do you know of any licensed retailer who has been invoiced for alcohol beverages that

was never delivered to or received by the retailer? (IF YES LIST) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________ ________

Have you sold any alcohol beverages to any person who was not a licensed retailer? (IF YES LIST) . . . . ________ ________

Have you delivered any alcohol beverages other than authorized samples to any licensed

retailer? (IF YES LIST) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______ ________

VERIFICATION: I hereby verify and declare, under penalties of perjury, that I have examined this report together with any attach-

ments thereto and to the best of my knowledge and belief the report is true, correct and complete.

EMPLOYED BY:

_____________________________________________

____________________________________________________

NAME OF WHOLESALER

SIGNED

Subscribed and sworn before me this ______________ day of ________________________ , 20_____

__________________________________________

NOTARY PUBLIC

SD REV SPT 117 (08/01)