Form Et-210 - Cuyahoga County Wine & Mixed Beverage Tax Return

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Excise Tax Form
ET-210 (Rev. 3/01)
P.O. Box 530= Columbus, OH 43216-0530
Cuyahoga County Wine & Mixed Beverage Tax Return
Return is due on or before the last day of the
Reporting Period
month following the reporting period.
For Treasurer of State
For the month of: _______________________________________________ , 20 _____
Use Only
Account Number __________________________________________________
Name __________________________________________________________
Address ________________________________________________________
City ________________________________ State __________ Zip _________
1. Gallons of Wine and Mixed Beverages Sold to Cuyahoga County Retailers ........................... $ ____________________
2. Gallons of Wine and Mixed Beverages Sold at Retail in Cuyahoga County ............................ $ ___________________
3. Sub-Total (Total of lines 1 & 2 X $ .32) .................................................................................... $ ___________________
4. Gallons of Cider Sold to Cuyahoga County Retailers .............................................................. $ ___________________
5. Gallons of Cider Sold at Retail in Cuyahoga County ................................................................ $ ___________________
6. Sub-Total (Total of lines 4 & 5 X $ .24) .................................................................................... $ ___________________
7. Gross Tax (Total of lines 3 & 6) ............................................................................................... $ ___________________
8. Discount (.025 X line 7) ........................................................................................................... $ ___________________
9. Net Tax (line 7 - line 8) ............................................................................................................ $ ___________________
10. Late Charge ($50.00 or 10% of line 7, whichever is greater) ................................................... $ ___________________
11. Total Amount Due (line 9 + line 10) .......................................................................................... $ ___________________
Make remittance payable to Treasurer of State of Ohio and mail to Treasurer of State, P.O. Box 16763, Columbus, OH 43216-6763.
This return must be received by the last day of the month following the reporting period.
I declare under penalties of perjury that this return, including any accompanying schedules and statements, has
been examined by me and, to the best of my knowledge and belief, is a true, correct and complete return and
report.
Signature ____________________________________________ Title ________________________________________
Date _______________________________________________

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