Dbpr Form Ab&t - Certificate Of Extraordinary Loss

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DBPR Form AB&T
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
4000A-037
DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO
Rev. 10/04
1940 NORTH MONROE STREET • TALLAHASSEE, FL 32399-1022
CERTIFICATE OF EXTRAORDINARY LOSS
Name
Date
Address
License Number
City of
FL
Zip Code
1.
Site of Extraordinary Loss
Investigating Agency
Incident Report #
Warehouse Loss
(Attach copy of report)
(Witnessed by Auditor/Agent)
2.
BEER
Detail of Gallonage involved in
LIQUOR
WINE
Total Gallons
Total Gallons
traffic accident: ATTACH COPIES
Pints or Less
Quarts
Bulk Gallons
OF ALL INVOICES IN SHIPMENT
TO THIS CERTIFICATE
3.
Gallonage by Tax Classification:
LIQUOR
WINE
Under
17.259%
Over
Natural
Over
Under
17.259%
-55.78%
55.78%
Sparkling
17.259%
17.259%
INVOLVED
RECLAIMED
DESTROYED
BEER
Pints or Less
Quarts
Bulk Gallons
INVOLVED
RECLAIMED
DESTROYED
4.
Site of destruction or reclamation:
a. Attach copy of landfill invoice or statement from site manager.
b. If reclaimed AUDITOR or AGENT must initial gallonage in #3.
I,
AN AUTHORIZED EMPLOYEE OF
, OF
FL
DO AGREE THAT THE ABOVE ENTRIES ARE TRUE AND CORRECT AND THAT THESE GALLONAGES WERE THE RESULT OF
EXTRAORDINARY LOSSES AS DEFINED BY RULE 7A-4.0371, AND THAT THESE GALLONAGES WERE DESTROYED OR
RECLAIMED IN ACCORDANCE WITH RULE 7A-4.0371.
Signature
Title
Date

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