Indiana Form Ab 910 - Indiana Brewers Excise Tax Report Form - Indiana Department Of Revenue

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Indiana Department of Revenue
Indiana Brewers Excise Tax Report
State Form #46776
Indiana Form AB 910
(R 7-02)
Reporting Month ________________ Year________________
Name (As Appears on Permit)
Indiana Brewer’s Permit Number
Address
Telephone Number
City/State
Zip Code
Federal Identification Number
Mail To:
Indiana Department of Revenue
P.O. Box 6114
Indianapolis, IN 46206-6114
1.
Gal.
1.
Gallons produced and sold in Indiana................. ........................................................................
2.
Multiply Line 1 by Tax Rate of .115...............................................................................................
2.
3.
Discount (Line 2 X .015) if timely filed..........................................................................................
3.
4.
If return is filed after due date, add 10% of line #2 (X.10) or $5.00, whichever is greater.
(Penalty is $5.00 if return is filed late with no tax due.)...............................................................
4.
5.
If return is filed late, add interest...................................................................................................
5.
6.
6.
Amount Due......................................................................................................................................
Discount (Line 3) does not apply unless the report and payment are timely filed. The report is due on or before the 20th day
of the month following the month being reported. A report must be filed even if there are no sales during the reporting
period.
I hereby certify, under penalty of perjury, that the information contained herein, and on supporting documents is to the best
of my knowledge true and correct.
(Name of Business or Taxpayer)
Signature of Agent or Officer
Date
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