Form B-4 - Monthly Indiana Beer Wholesalers Purchase Report Of Beer Received From An Indiana Brewery

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Indiana Department of Revenue
Monthly Indiana Beer Wholesalers Purchase
B-4
State Form #46760
Report of Beer Received from an Indiana Brewery
Revised 3/95
Reporting Month ________________ Year________________
Name (Wholesaler As appears on Permit)
Federal I.D. Number
Address
City
State
Zip
State Beer Permit Number
This Schedule must be attached to Revenue Form 810
Mail To:
Indiana Department of Revenue
P.O. Box 6114
Indianapolis, IN 46206-6114

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