Form Wld-210 - Report Of Inspection And Claim For Concealed Loss Or Damage

WLD-210 (7/14)

WYOMING LIQUOR DIVISION

---W.L.D. OFFICE USE ONLY---

REPORT OF INSPECTION

AND

WLD Agent:

Date:

/

/

CLAIM FOR CONCEALED LOSS OR DAMAGE

(As Invoiced)

---DISPOSITION OF RETURNED MERCHANDISE---

LICENSEE: CUSTOMER NUMBER:

NAME:



ADDRESS:

DESTROYED

LOCATION:

, WYOMING



RETURNED

To save time issuing credit due, LICENSEE please fill in appropriate Vendor Rep information.

Signature of Vendor Representative acknowledges receipt and removal of merchandise listed and approves

W.L.D. Remarks:

claim for credit.

VENDOR REPRESENTATIVE NUMBER:

VENDOR REPRESENTATIVE NAME:______________________________________________________

VENDOR REPRESENTATIVE SIGNATURE:

DATE:

/

/

Quantity

Invoice

Claimed

Code

Size

Description of Article

LOSS/DAMAGE Description

Number

Invoice Date

LOSS OR PILFERAGE: Upon delivery, was container  sealed;  open;  or re-boxed?

I, or we, hereby make further statement that the above and foregoing claim is just and correct and has not been paid, nor any part thereof, by the State of Wyoming, or the Wyoming

Liquor Division or any other person.

Date:

Licensee or Authorized Signature:

(CUT ALONG DOTTED LINE AND MAINTAIN LOWER PORTION FOR YOUR RECORDS)

Quantity

Invoice

Claimed

Code

Size

Description of Article

LOSS/DAMAGE Description

Number

Invoice Date

LOSS OR PILFERAGE: Upon delivery, was container  sealed;  open;  or re-boxed?

IMPORTANT - READ INSTRUCTIONS - INCOMPLETE FORMS CANNOT BE ACCEPTED

1.

ATTN: LICENSEE: This claim form must be entirely completed. Incomplete forms may be rejected by the Wyoming Liquor Division.

2.

Claims over six (6) months old will not be honored.

3.

Only those items handled by a single representative may be on one form. Please match Representative Codes with the Representative Names in the Wholesale Price List

carefully for the speedy processing of your claim.

4.

All claimed items and forms must be retained for collection by Wyoming Liquor Division Agent or authorized WLD Personnel or the Representative of the product.

BROKEN BOTTLES - Any claim for damage incurred by the carrier, i.e. “wet breakage” at time of delivery, must be filed with the carrier - NOT the Wyoming Liquor Division.

5.

6.

MISSING BOTTLES - The original carton(s) must be retained for inspection purposes.

7.

MISORDER/MISSHIPMENT - Must be reported immediately upon receipt of the merchandise, no claim form is necessary.

8.

SPECIAL ORDERED MERCHANDISE- These claims are subject to approval of the Supplier and credit will not be issued until payment is received from them.

9.

WINE DIRECT SHIP AND MALT BEVERAGE MERCHANDISE-Do not utilize this form! These claims are filed directly with the Supplier-NOT the Wyoming Liquor Division.