Form 720x - Amended Quarterly Federal Excise Tax Return Page 2

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Form 720X (Rev. 3-2013)

Page

Explanation of adjustments. See the instructions for line 6 for requirements. Attach additional sheets with your name and EIN

if more space is needed.

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is

true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Sign

Here

Signature

Date

Title

Type or print name below signature.

Print/Type preparer’s name

Preparer's signature

Date

PTIN

Paid