Wine Distributor'S Report Form

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STATE OF WEST VIRGINIA
State Tax Department, Tax Account Administration Div
P.O. Box 2991
Charleston, WV 25330-2991
Craig A. Griffith, Tax Commissioner
Earl Ray Tomblin, Governor
Name
Address
Account #:
City
State
Zip
WV/DIS-01
WEST VIRGINIA WINE DISTRIBUTOR'S REPORT
rtL167 v.4-Web
NOTE: This return has been redesigned. To avoid delays in the processing of this return, DO NOT use any older forms you may have. For
information regarding the State Tax Department’s new computer system, visit our website at
This report must be filed even if no activity has occurred
**Prepare this report in duplicate and mail the original with invoices and payment of taxes to the WV State Tax Department.
Mail a copy of return and invoices to Alcohol Beverage Control Administration, 322 70th St. SE, Charleston, WV 25304 on or before the 15th day of each month.**
Period Ending:
Due Date:
FINAL
AMENDED
SUMMARY OF WINE PURCHASES, SALES & INVENTORY
1.
Inventory Beginning of Month
.
2.
Supplier Purchases Received During Month (Schedule A Total)
.
3.
Transfers In (Schedule B Total)
.
4.
Pickups
.
5.
Total (Add Lines 1 through 4)
.
6A.
Breakage, Leakage, Spoilage and Shortages (From Page 3 Schedule D)
.
6B.
Samples (From Page 3 Schedule E)
.
7.
Transfers Out (Schedule C Total)
.
8.
All Other Transfers Out
.
9.
Total Liters Sold to Retailers & Clubs During Month
.
10.
Total Depletions of Inventory (Add Lines 6 through 9)
.
11.
Inventory at End of Month (Line 5 minus Line 10)
.
Sign Your Return
Under penalties of perjury, I declare that I have examined this return (including accompanying schedules and statements) and to the
best of my knowledge and belief it is true and complete.
(Signature of Taxpayer)
(Name of Taxpayer - Type or Print)
(Title)
(Date)
(Person to Contact Concerning this Return)
(Telephone Number)
(E-mail Address)
(Signature of preparer other than taxpayer)
(Address)
(Date)
MAIL TO: WEST VIRGINIA STATE TAX DEPARTMENT
Tax Account Administration Div
P.O. Box 2991, Charleston, WV 25330-2991
FOR ASSISTANCE CALL (304) 558-3333 TOLL FREE (800) 982-8297
For more information visit our web site at:
File online at https://mytaxes.wvtax.gov
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