Out Of State Supplier Report Of Alcoholic Beverages Shipped To Delaware Importers Form

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OUT OF STATE SUPPLIER REPORT OF ALCOHOLIC BEVERAGES SHIPPED
TO DELAWARE IMPORTERS
TO: DELAWARE DIVISION OF REVENUE
TYPE
BUSINESS AUDIT BUREAU
W = WINES
ATTN: William J. Kirby
HS = HIGH SPIRITS
820 N. FRENCH STREET
LS = LOW SPIRITS
WILMINGTON, DE 19801
C = CIDER
WILLIAM.KIRBY@STATE.DE.US
B = BEER
Shipments of alcoholic beverages to Delaware Importers
for the month of:
License No.
Check here if you had no shipments to report during this month.
TYPE
TOTAL
TOTAL
INVOICE
P.O.
NAME OF DELAWARE
W,HS.LS
TOTAL
GALLONS
BARRELS
DATE
NUMBER
NUMBER
IMPORTER
C,B
CASES (W,HS,LS,C)
(BEER)
The information submitted in the foregoing report is certified to be a full, true and correct statement of the out of state supplier named
below to the knowledge and belief of the undersigned. Copies of invoices are not required. Report is due by the 15th of the month.
NAME OF SUPPLIER
DATE
NAME OF OFFICER
SIGNATURE
TELEPHONE NUMBER

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