Form Ltd 04et - Supplier Liquor Excise Tax Report - Sales To Consumers - 2004
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1
2NEVADA DEPARTMENT OF TAXATION
1550 E. COLLEGE PARKWAY STE. 115
CARSON CITY NV 89706
(775) 684-2122
SUPPLIER LIQUOR EXCISE TAX REPORT - SALES TO CONSUMERS
TH
THIS RETURN TO BE FILED ON OR BEFORE THE 20
OF THE MONTH FOLLOWING ACTIVITY.
______________
___________________
NEVADA CERTIFICATE OF COMPLIANCE NO.
REPORT PERIOD
Month/Year
________________________________________________________________________________________________
(Supplier’s Name)
________________________________________________________________________________________________
(Address)
________________________________________________________________________________________________
(City)
(State)
(Zip Code)
See Instructions And Wine Gallon Conversion On The Other Side
COPIES OF INVOICES WITH NAME AND ADDRESS OF RECIPIENT MUST ACCOMPANY THIS REPORT
LIQUOR TYPE
WINE GALLONS
TAX RATE
TAX AMOUNT DUE
1. BEER
$ .16
2. WINE .5% TO 14%
$ .70
3. WINE 14.1% TO 22%
$ 1.30
4. LIQUOR 22.1% TO 80%
$ 3.60
. TOTALS:
5
$
6. If paid on or before the 15th of the month, 0.5% Discount:
$
7.
TOTAL DUE:
$
The foregoing report in all respects is true and correct to the best of my knowledge and belief, together with all
attachments; I am the Supplier, or officer of the Supplier and duly qualified and authorized to verify this report.
8. Prepared by __________________________
9. Signed ______________________________________________
10. Checked by___________________________
11. Title __________
12. Phone No (
)__________________
FOR OFFICE USE ONLY
Date:
Check No.:
Check Amount:$
Amount Paid: $
2/04
Postmark:
Initials:
LTD 04ET
CONSUMER SALES
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