Form Wv/ber-01 - Report For Distributors And/or Wholesalers Of Nonintoxicating Beer Page 2

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BREWER PURCHASES (CON'T)
INVOICE DATE
INVOICE #
BREWER
QUANTITY RECEIVED
TOTAL PURCHASES
TRANSFERS IN - DISTRIBUTOR
TRANSFERS OUT - DISTRIBUTOR
CERTIFICATION TO REPORT:
I DECLARE UNDER THE PENALTY OF PERJURY, THAT THE INFORMATION CONTAINED IN THIS REPORT IS TRUE AND
CORRECT. RECORDS ARE AVAILABLE TO SUPPORT THESE STATEMENTS.
SIGNATURE
DATE
COMPUTER PRINT-OUT OF THIS DATA PERMITTED.
ATTACH INVOICE COPIES TO REPORT.

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