Form Lb91 - Certificate Of Destruction - Wine And Cider
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1LB91
Certificate of Destruction — Wine and Cider
You must obtain prior approval from the Minnesota Department of Revenue before destroying merchandise.
Claim the credit on your next tax return. You must attach this form to your return. Keep a copy for your records.
Check if amended
Company name
FEIN
Address
Minnesota tax ID number
Location code
City
State
Zip
Period claiming credit on
A
B
Destroyed Wine and Cider
Bottles
Liters
1 Wines 14% or less . . . . . . . . . . . . . . . . . . . . . . 1
2 Wines more than 14% to 21% . . . . . . . . . . . . . 2
3 Wines more than 21% to 24% . . . . . . . . . . . . . 3
4 Wines more than 24% . . . . . . . . . . . . . . . . . . . 4
5 Sparkling wine . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Cider. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 Total bottles
7
(add lines 1 through 6, column A)
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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Parent category: Financial