Form 67-103 - Texas Mixed Beverage Sales Tax Report
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1AB CD
*6710300W021603*
67-103
b.
PRINT FORM
CLEAR FIELDS
b
(Rev.2-16/3)
Texas Mixed Beverage Sales Tax Report
This report is due in addition to the Texas Mixed Beverage Gross Receipts Report
Page 1 of ______
and Texas Sales and Use Tax Report required by Texas law.
b
63100
a. T Code
c. Taxpayer number
e.
d. Filing period
f. Due date
b
b
g. Name and mailing address (Make any necessary name changes below.)
IMPORTANT
Black out this box if your mailing
address has changed. Show changes
1.
b
R
by the preprinted information.
If you are no longer in business or your business name
and/or location has changed, refer to the Business
Changes instructions on the back of this form.
h.
i.
b
b
- A report must be filed even if no tax is due.
under Chapters 552 and 559, Government Code, to review, request and correct information
You have certain rights
- Do not write in shaded areas.
we have on file about you. Contact us at the address or phone number listed on this report.
b
b
b
TABC
Total
Total
3
.
5.
1.
2.
4
.
Location
Permit
Mixed Beverage
Mixed Beverage
Business Location Name and Address
Number
Number
Sales
Taxable Sales
.00
.00
.00
.
00
.00
.
00
.00
.
00
.00
.
00
b
63180
k. T Code
b
(Item 5 from this and all supplemental pages)
6. Total mixed beverage taxable sales for ALL locations
6.
.00
b
.082500
7. Tax rate
7.
b
(Multiply Item 6 by Item 7)
8. Total tax due
8.
67-103
(Rev.2-16/3)
(See instructions)
9. Penalty
9.
(See instructions)
10. Interest
10.
b
(Item 8 plus Item 9 and Item 10)
11. Total amount due and payable
11.
Taxpayer name
l.
m.
b
AB
b
b
b
T Code
Taxpayer number
Period
I declare that the information in this document and any attachments is true
and correct to the best of my knowledge and belief.
Duly authorized agent
Make the amount in Item 11 payable to:
STATE COMPTROLLER
Mail to: Comptroller of Public Accounts
Daytime phone
Date
(Area code and number)
P.O. Box 149356
Austin, TX 78714-9356
For assistance call 1-800-252-5555 .
111 A
Details are also available online at
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