Form Wld-34 - Wholesalers Monthly Report Of Excise printable pdf download

Form Wld-34 - Wholesalers Monthly Report Of Excise

WLD-34 (9/97)

WHOLESALERS

Mail this form along with payment to:

State of Wyoming

MONTHLY REPORT OF EXCISE

(Regulations

require

report

and

WYOMING LIQUOR DIVISION

payment due no later than 15th of

TAX

Cheyenne, Wyoming 82002-0110

month following purchase)

Report of Malt Beverage products purchased from breweries or out of state wholesalers:

Wholesaler:

Page

Month of:

Address (P.O. Box, Street, City, State, Zip):

Phone Number:

GALLONS

DATE

PURCHASED FROM:

INVOICE NUMBER

(Nearest Hundredth)

Total Gallons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tax per Gallon ($ .005 per liter) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.019

Tax Due this page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

+/- Previous Page or last month Adjustment. . . . . . . . . . . . . . . . . . . . . .

Total Tax Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I do solemnly swear that the foregoing is a true and correct statement of all beer manufactured or imported into the state during

the month for which this report is rendered, to the best of my knowledge and belief.

Date Signed:

Printed Name:

Signature:

H:bjr\WLD Forms\00-99\WLD-034\Wholesalers Mo Report of Excise Tax

Form Wld-34 - Wholesalers Monthly Report Of Excise