Form Abp1-Wl - Primary Source Supplier'S Monthly Report Page 2
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1
2INDIANA DEPARTMENT OF STATE REVENUE
PRIMARY SOURCE SUPPLIER’S MONTHLY REPORT
Page
of
Form ABP1-WL
State Form 46919
(R2/ 3-09)
NAME OF PERMIT HOLDER
REPORTING MONTH/YEAR
ABC PERMIT #
FEDERAL ID#
Sold To
Invoice
Invoice
Gallons
Gallons
Date
Number
Name
Address
Wine
Liquor
NOTE:
Do not combine invoices. A liquor product with a volume of 15% or less alcohol is considered to be a wine.
Total
A fortifi ed wine product with a volume 21% or more of alcohol is considered to be a liquor.
Gallons
Questions related to this form call (317) 615-2710
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