City Of Villa Rica Alcoholic Beverage (Mixed Drinks Only) Excise Tax Reporting Form

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THIS REPORT IS DUE BY THE 20
OF EACH MONTH
City of Villa Rica Alcoholic Beverage (Mixed Drinks Only) Excise Tax Reporting Form
Month Ending___________, 2_______. Named Licensee______________________________________
Business Name________________________________________________________________________
Address______________________________________________________________________________
A. Inventory reporting liquor only:
List your inventory purchases from licensed wholesaler for monthly period:
1.
Dixie Bottle_________ Liters
6. National Dist.__________
2.
Empire Dist._________ Liters
7. United Dist.___________
3.
General Whls.________Liters
8. State Whls.____________
4.
Georgia Crown_______Liters
9.
_____________________
5.
McKesson Liq._______ Liters
10. _____________________
Total Liters Purchased: _______________________
B. Excise Tax Reporting:
1. Alcoholic Beverage License No:____________________________________
2.
Gross alcoholic beverage by the drink sales (Mixed Drinks Only):_______
3.
*Tax 3 % of Line 2._____________________________________________
4.
Less 3 % of Line 3. (as collection fee):______________________________
5.
TOTAL AMOUNT TO BE PAID_________________________________
th
*If paid by the 20
of each month
C. Average:
1. Average ounces per drink poured:_________________________________
2.
Average price per drink sold:_____________________________________
I (we) do solemnly swear subject to criminal penalties for false swearing, that the information contained herein
is true, and no false or fraudulent information is made herein. I (we) further swear that all records required
under Section 3.74 of the Alcoholic Beverage Ordinance of the City of Villa Rica are maintained and open for
inspection by authorized agents of the City.
Date:__________, 2_____.
_____________________________________________________________
Printed Name/Signature of person responsible for Preparing Report
Date:__________, 2_____.
_____________________________________________________________
Printed Name/Signature of named Licensee
NOTICE: Section 3.26 (6) of the Alcoholic Beverage Ordinance of the City of Villa Rica provides that failure to
properly account for, file, report, maintain records and pay any excise tax levied under this ordinance shall be
cause for automatic revocation of the license by operation of law.
Section 3-181 of the Alcoholic Beverage Ordinance of the City of Villa Rica requires that a record of each mixed
drink sale will be made in writing and maintained for inspection by any authorized agent of the City.
THIS REPORT MUST BE FILED WITH THE OFFICE OF THE COMMUNITY DEVELOPMENT
TH
DEPARTMENT BY THE 20
OF EACH MONTH. REPORTS MAY BE MAILED OR DELIVERED TO:
CITY OF VILLA RICA, COMMUNITY DEVELOPMENT DEPARTMENT, 571 W. BANKHEAD HWY.
VILLA RICA, GA 30180

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