Form Rev-1053 As - Schedule "A" Malt Beverage Sales To Distributors Or Customers In Pa (Rev-1053)

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Federal EIN:
REV-1053 AS (5-05)
SCHEDULE “A”
License Number:
Date:
MALT BEVERAGE SALES TO DISTRIBUTORS OR CUSTOMERS IN
MAIL TO:
COMMONWEALTH OF PENNSYLVANIA
PENNSYLVANIA
Report Month/Year:
DEPARTMENT OF REVENUE
BUREAU OF BUSINESS TRUST FUND TAXES
County:
PO BOX 280909
Please Print or Type - Attach to REV-1052
Telephone Number
HARRISBURG, PA 17128-0909
NAME OF MANUFACTURER
ADDRESS
UNITS
OTHER
BARRELS
OTHER
INVOICE
NAME AND ADDRESS OF DISTRIBUTOR/CUSTOMER
INDICATE SIZE
INDICATE SIZE
NUMBER
Can & Bottle
Can & Bottle
Can & Bottle
Can & Bottle
Can & Bottle
GALLON
1/8
1/6
1/4
1/2
7 oz. to 8 oz.
8.1 oz. to
12 oz. to
16.1 oz. to
24 oz. to
128 oz.
11.9 oz.
16 oz.
23.9 oz.
32 oz.
Name
Street Address
City
State
Zip Code
Name
Street Address
City
State
Zip Code
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Street Address
City
State
Zip Code
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Street Address
City
State
Zip Code
Name
Street Address
City
State
Zip Code
Name
Street Address
City
State
Zip Code
Name
Street Address
City
State
Zip Code
Name
Street Address
City
State
Zip Code
Name
Street Address
City
State
Zip Code
Name
Street Address
City
State
Zip Code
TOTALS

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Parent category: Financial
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