Form Abcc-Ws-3-S - Direct Shipper'S Report Of Wine Sales And Taxes On Shipments Into West Virginia

DIRECT SHIPPER’S REPORT

FORM ABCC-WS-3-S

OF WINE SALES AND TAXES ON SHIPMENTS INTO WEST VIRGINIA

FEIN:

REPORT FOR THE MONTH ENDING

MM

DD

YEAR

DIRECT SHIPPER NAME:

WVABCA License#:

Phone Number:

ADDRESS:

CITY, STATE, ZIP:

**Prepare this report in duplicate, mail the original and payment of taxes to the WV State Tax Department, Internal Auditing Division, PO Box 2666, Charleston, WV 25330-2666 and

a copy to Alcohol Beverage Control Administration, 332 70th St, SE, Charleston, WV 25304 on or before the 15th day of each month.**

Column 1

Column 2

Column 5

Column 7

Column 8

Column 3

Column 6

Column 4

Invoice Date

Invoice

WVABCA Permitted Carrier

Total Invoice

Freight Bill or

Customer Name:

Total Inovice

City

Number

Making Delivery

Wine Liters

Tracking #

Cost

1. Total Liters (add all Column 5 entries)

2. Total Invoice Cost (add all Column 6 entries)

3. Total State Excise Tax (Line 1 x $.26406)

SIGNATURE

DATE

*O54050701W*

I declare under penalty of perjury under the laws of the state of West Virginia that the foregoing is true and correct.