Form Ltd 1 - Liquor Excise Tax Return - Nevada Department Of Taxation Page 4

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ALCOHOLIC BEVERAGES ENTERED AND WITHDRAWN FROM BONDED WAREHOUSES
Total Withdrawn
Name of Supplier Purchased From
Bond No.
Name or Type of Liquor
Date
Gallons
Including Losses
Withdrawn
This Month
Name of Bonded Warehouse, Broker, etc.
Invoice No.
Percent Alcohol
Original Gallons
Balance in Bond
ENTER TOTALS FROM BOND UNDER PROPER CATEGORY AT BOTTOM OF PAGE 3
Page 4

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