Dbpr Form Ab&t 4000a-005exm - Exempt Inventory Certification Worksheet -
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1DBPR Form AB&T
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
4000A-005EXM
DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO
Rev. 12/03
1940 NORTH MONROE STREET • TALLAHASSEE, FL 32399-1022
SURCHARGE NONPROFIT EXEMPTION STATUS SHEET
AND INVENTORY CERTIFICATION
Beginning on July 1, 2000, various nonprofit organizations are exempt from paying all alcoholic beverage surcharges. Any organization that is
licensed by the Division of Alcoholic Beverages and Tobacco under sections 565.02(4) and 561.422, Florida Statutes, as an alcoholic
beverage consumption on premises vendor, and who is currently exempt by the Internal Revenue Service from federal income tax under
section 501(c)(3), (4), (5), (6), (7), (8), or (19), Internal Revenue Code of 1986, as amended, will be exempt from paying surcharge. To
ensure that all alcoholic beverage consumption on premise licensees who meet this criteria are exempted by the Division, section A of this
form must be completed and returned to the Division, along with a copy of the IRS federal income tax exemption certificate. Each qualifying
licensee on the "Purchases" method should also complete section B of this form certifying the accuracy of the beginning of business
inventory for July 1, 2000. The form should then be submitted to the Division of Alcoholic Beverages and Tobacco at the address on the
bottom of the form.
Once the exemption has been approved, the Division will conduct a final audit with the licensee, and any pre-paid surcharge on the inventory
will be refunded.
SECTION A:
Business Name
License Number
Series
Busn.
Contact Person
Telephone
(
)
Home
Mailing Address
Location Address
City
FL Zip
City
Zip
Federal Employer Identification Number (FEIN)
Attach copy of IRS exemption approval letter
EXEMPT INVENTORY CERTIFICATION WORKSHEET
SECTION B:
For Nonprofit Organizations Reporting Using The "Purchases" Method Only
Inventory
Surcharge
Less
Adjusted
Rate
Surcharge Amounts
DAB&T
Gallons
Category
Spillage
Gallons
Amounts
use only
10%
$
0.14
Draft Beer
@
@
5%
$
0.14
Beer
@
@
5%
$
0.14
Coolers
@
@
5%
$
0.14
Cider
@
@
5%
$
1.04
Wine
@
@
10%
$
4.28
Liquor
@
@
As the owner or authorized representative of this alcoholic beverage license, I certify that the "Purchases" method is used to calculate the
beverage surcharge, and that all surcharges have been paid on the product held in inventory for consumption on the licensed premises at the
beginning of business July 1, 2000. I further certify that appropriate documentation will be retained and made available to DAB&T staff to
substantiate the inventory claim as submitted. I further certify that this license is exempt from federal income tax under s. 501(c)(3), (4), (5),
(6), (7), (8), or (19), Internal Revenue Code of 1986, as amended.
This completed form should be submitted to:
Authorized Signature
Division of Alcoholic Beverages and Tobacco
1940 North Monroe Street
Tallahassee, FL 32399-1022
Title
Date
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