Schedule A (Form Rev-1053) - Malt Beverage Sales To Distributors And/or Customers In Pennsylvania

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SCHEDULE A
REV-1053 AS+ (04-11)
BUREAU OF BUSINESS TRUST FUND TAXES
MALT BEVERAGE SALES TO DISTRIBUTORS AND/OR
MISCELLANEOUS TAX DIVISION
CUSTOMERS IN PENNSYLVANIA
PO BOX 280909
HARRISBURG PA 17128-0909
Attach to REV-1052
Print or Type
BUSINESS NAME
DATE
ACCOUNT NUMBER
EIN
LID NUMBER
REPORTING MONTH/YEAR
UNITS
OTHER
BARRELS
OTHER
INVOICE
Can &
Can &
Can &
Can &
Can &
INDICATE SIZE
INDICATE SIZE
NAME AND ADDRESS OF DISTRIBUTOR/CUSTOMER
Bottle
Bottle
Bottle
Bottle
Bottle
GALLON
NUMBER
1/8
1/6
1/4
1/2
7 oz. to
8.1 oz. to
12 oz. to
16.1 oz. to
24 oz. to
128 oz.
8 oz.
11.9 oz.
16 oz.
23.9 oz.
32 oz.
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
TOTALS

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