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Form Ltd 2 - Liquor Importer/wholesaler Monthly Report Of Loss - Nevada Department Of Taxation

NEVADA DEPARTMENT OF TAXATION

1550 E COLLEGE PARKWAY

CARSON CITY, NEVADA 89706

LIQUOR IMPORTER/WHOLESALER MONTHLY REPORT OF LOSS (NRS 369.370)

Excise tax credit (as shown on LTD 1) for alcoholic beverages lost, stolen or damaged in transit or on

premises, for the month of

, 20

By the firm of

Street

City

This report must be made monthly to the Department of Taxation. Attach copies of all supporting loss

claims which have been filed with carriers, shippers, etc.

MALT BEVERAGES

ALCOHOLIC BEVERAGES

BOTTLE

DATE

EXPLAIN TYPE OF LOSS, SHIPPER,

KEG

GALLONS

OR CAN

BRAND NAME, ETC.

.5% to 14%

14.1% to 22%

22.1% to 80%

GALLONS

GALLON TOTALS:

LESS .5% FORMERLY DISCOUNTED:

TOTAL, ENTER ON LINE 2 OF TAX RETURN:

The foregoing report is true and correct to the best of my knowledge and belief.

Signed ..................................................................................

Title.......................................................................................

LTD 2 (10/03)

Form Ltd 2 - Liquor Importer/wholesaler Monthly Report Of Loss - Nevada Department Of Taxation