Certified Statement Of Wines, Cider, Spirits And Beer Purchases

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STATE OF DELAWARE - DEPARTMENT OF FINANCE - DIVISION OF REVENUE
CERTIFIED STATEMENT OF WINES, CIDER, SPIRITS AND BEER PURCHASES
NAME OF IMPORTER______________________ MONTH __________________ EIN: ____________________
EXACT
EXACT
EXACT
EXACT
EXACT
GALLONAGE
GALLONAGE
GALLONAGE
GALLONAGE
BARRELAGE
WINE
CIDER
HIGH SPIRITS
LOW SPIRITS
BEER
GRAND TOTALS
TAX RATE
@ $.97
@ $.16
@ $3.75
@ $2.50
@ $4.85
TAX DUE
CREDITS TAKEN
(attach copy
of tax credit report)
TAX PAID
$
TOTAL REMMITTANCE =
I hereby certify under the penalties of perjury that the above report has been examined by me and to the best of my
knowledge and belief is true and correct:
BY: ____________________________________________
Page No. _____________________
(Please Submit in Triplicate)

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