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Form Wv/bls-01 - Distributor'S Monthly Report Of Breakage, Leakage, Spoilage, Shortages & Samples

For the Period Ending:

DISTRIBUTOR'S MONTHLY REPORT OF BREAKAGE, LEAKAGE, SPOILAGE, SHORTAGES & SAMPLES

Distributor Name:

FEIN#:

Listed below is an account of that merchandise included in Item 6 of the Distributor's Summary of Wine

Purchases, Sales and Inventory (WV/DIS-01), submitted to the West Virginia Department of Tax and Revenue

for the above reporting period.

DISTRIBUTOR'S BREAKAGE, LEAKAGE, SPOILAGE & SHORTAGES

(Itemization is not required. Enter total only of Breakage, Leakage,

Spoilage & Shortages on Line 6-A)

___________________________

DISTRIBUTOR'S SAMPLES TO RETAILERS (Itemization is required.

Enter each sample given in the reporting period as a separate item).__________________

Quantity

License

Extended

Date

Retailer

Brand Name

Size

Number

(Bottles)

Liters

TAX CODE 25

USE BLACK OR BLUE INK ONLY--DO NOT PHOTOCOPY

TOTAL LITERS OF SAMPLES GIVEN TO RETAILERS

(To be entered on Line 6-B)

WV/BLS-01(rev 12-06)

This report is to be attach to and submitted with the Distributor's Summary of Wine Purchases, Sales & Inventory.

*O34120601W*

Form Wv/bls-01 - Distributor'S Monthly Report Of Breakage, Leakage, Spoilage, Shortages & Samples