Form Lb93 - Certificate Of Destruction - Malt Beverages

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LB93
Certificate of Destruction — Malt Beverages
You must obtain prior approval from the Minnesota Department of Revenue before destroying merchandise.
Submit a copy of this form to your supplier (brewer or importer) to obtain credit for excise tax paid on products destroyed.
Check if amended
Company name
FEIN
Address
Minnesota tax ID number
Location code
City
State
Zip
Return claiming credit on
Malt Beverages Destroyed
Quantity
Size
Brand
More Than 3.2%
3.2% or Less
Totals
I declare that this return is correct and complete to the best of my knowledge and belief.
Authorized signature
Date
Print name
Title
Daytime phone
Signature of department representative (optional)
Print name of department representative
Title
Mail to: Minnesota Revenue, Mail Station 3331, St. Paul, MN 55146-3331
Phone: 651-556-3036 TTY: 711 Minnesota Relay Fax: 651-556-5236 Email: alc.taxes@state.mn.us
(Rev. 1/12)

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