Certified Statement Of Wines, Cider, Spirits And Beer Purchases Page 2

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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__________________ PERIOD BEGINNING _______________ ENDING _________________
GALLONS
BARRELS
INVOICE
P.O.
DATE
NO. OF
HIGH
LOW
RECEIVED FROM
WINE
CIDER
BEER
NO.
NO.
REC.
CASES
SPIRITS
SPIRITS
SUBTOTALS
Page No. _____________________

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