Form Ltd 5 - Carrier'S Report Of Interstate Shipments Of Alcoholic January 2001

CARRIER’S REPORT OF INTERSTATE SHIPMENTS OF ALCOHOLIC

Form LTD 5 (1/01)

BEVERAGES DESTINED TO NEVADA POINTS

NEVADA REVISED STATUTE 369.450

NEVADA DEPARTMENT OF TAXATION

LIQUOR TAX DIVISION

1550 E. COLLEGE PARKWAY

CARSON CITY NV 89706

Page .......... of ...........

Name of Carrier .................................................................. Address ................................................................................................................ Reporting for month of ........................................., 20 ..............

th

This report must be filed with the Nevada Department of Taxation, Carson City, Nevada on or before the 10

of each month following delivery in Nevada.

DESCRIPTION OF ALCOHOLIC BEVERAGE

FREIGHT BILL

DELIVERED TO

NEVADA

SHIPPER

ORIGIN

Delivery Date

Number

CONSIGNEE

DESTINATION

No. Pkgs.

Type Pkg.

Kind

THE UNDERSIGNED HEREBY CERTIFIES THAT THE FOREGOING REPORT IS MADE PURSUANT TO CHAPTER 369 OF NRS, AS AMENDED, AND COVERS THE MONTH SHOWN ABOVE FOR THE

COMMON OR CONTRACT CARRIER NAMED IN THIS REPORT AND IS CORRECT TO THE BEST OF THE KNOWLEDGE AND BELIEF OF THE UNDERSIGNED.

Dated .........................................., 20 ........., at ................................................................... Signed ................................................................................. Telephone (...........)................................................