Form 67-100 - Texas Mixed Beverage Gross Receipts Tax Report - 2017
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1
2AB CD
*6710000W021717*
67-100
PRINT FORM
CLEAR FIELDS
b.
(Rev.2-17/17)
b
Texas Mixed Beverage Gross Receipts Tax Report
This report is due in addition to the Texas Mixed Beverage Sales Tax Report and Texas Sales and Use Tax Report required by law.
Page 1 of ______
73100
a. T Code
Do not write in shaded areas.
b
I
c. Taxpayer number
d. Filing period
e.
f. Due date
m
m
d
d
y
y
y
y
Month ending
b
b
IMPORTANT
g. Name and mailing address (Make any necessary name or address changes below.)
Black out this box if your mailing
address has changed. Show changes
1.
by the preprinted information.
R b
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
Business
TABC Permit
location name:
Location number:
b
number:
Address:
1. Dollar amount (retail selling price) of complimentary
REPORT WHOLE DOLLARS ONLY
(See instructions on back)
drinks for this location
1.
.00
b
2. Gross sales of liquor for this location
2.
.
00
b
3. Gross sales of wine for this location
3.
.00
b
4. Gross sales of beer and malt liquor for this location
4.
.00
b
5. Gross cover charges (subject to gross receipts tax and not subject to sales tax)
(See instructions on back)
.00
for this location
5.
b
(Total of Items 2, 3, 4 and 5)
6. Total gross taxable amount for this location
6.
.00
b
For Items 7 - 11 REPORT WHOLE DOLLARS ONLY
j. T Code
73180
b
7. Total gross sales of liquor FROM ALL LOCATIONS
(Item 2 on this page plus the total of Item 7 from all supplement pages, Form 67-101)
7.
.00
b
8. Total gross sales of wine FROM ALL LOCATIONS
(Item 3 on this page plus the total of Item 8 from all supplement pages, Form 67-101)
8.
.00
b
9. Total gross sales of beer and malt liquor FROM ALL LOCATIONS
(Item 4 on this page plus the total of Item 9 from all supplement pages, Form 67-101)
9.
.00
b
10. Total gross cover charges FROM ALL LOCATIONS
(Item 5 on this page plus the total of Item 10 from all supplement pages, Form 67-101)
10.
.00
b
(Total of Items 7, 8, 9 and 10)
11. Total gross amount FROM ALL LOCATIONS
11.
.00
b
[ Multiply Item 11 by tax rate of .067 (6.7%). ENTER DOLLARS AND CENTS]
12. Total tax due
_________.
12.
.
b
(See instructions on back)
13. Penalty
13.
.
(See instructions on back)
14. Interest
14.
.
(Item 12 plus Item 13 and Item 14)
15. TOTAL AMOUNT DUE AND PAYABLE
15.
.
b
Taxpayer name
k.
l.
AB
b
Taxpayer number
Period
T Code
b
b
b
I declare that the information in this document and any attachments is true and correct to
the best of my knowledge and belief.
Taxpayer or duly authorized agent
Make the amount in Item 15 payable to: STATE COMPTROLLER
Daytime phone
Date
Mail to: COMPTROLLER OF PUBLIC ACCOUNTS
P.O. Box 149356
Austin, TX 78714-9356
111 A
67-100 (Rev.2-17/17)
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