Form Sfn 22910 - Alcoholic Beverage Supplier License Application Page 3
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6North Dakota Office of State Tax Commissioner
Schedule A - Supplier's Monthly Liquor Report of Sales to ND Wholesalers
Report Period
(YYYYMM i.e. 200507)
Supplier Name
FEIN:
ND Supplier License #:
Address:
State:
Zip Code:
City:
Prepared By:
Phone Number:
E-mail Address:
Sales/Returns
Total Report Volume in Gallons
When submitting multiple pages see instructions
(converted from liters - factor .026417)
for entering total volumes
Total Report Volume in Liters
ND Liquor
Sparkling Wine\
Wine 17-24%
Wine Under 17%
Invoice
Wholesaler Account
Distilled Spirits
Champagne
Alcohol By Volume
Alcohol By Volume
Invoice Date
Number
Number
ND Liquor Wholesaler Name
Alcohol (Liters)
(Liters)
(Liters)
(Liters)
(Liters)
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Parent category: Financial