Form Rev-1014 - Distributor'S Monthly Report

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REV-1014 AS+ (04-12)
BUREAU OF BUSINESS TRUST FUND TAXES
DISTRIBUTOR’S MONTHLY REPORT
MISCELLANEOUS TAX DIVISION
MALT BEVERAGE PURCHASED, SOLD AND
PO BOX 280909
WITHDRAWN INVENTORIES
HARRISBURG PA 17128-0909
Print or Type
BUSINESS NAME
ADDRESS
STREET
CITY
STATE
ZIP
REPORTING MONTH/YEAR
EIN
LICENSE NUMBER
LID NUMBER
INSTRUCTIONS:
1. This report and its schedules are due on or before the 15th day after the end of the month for which it is prepared.
2. Type or print figures legibly. Only use black ink when completing reports. Do not use colored ink or pencil.
3. Mail report and schedules to PA DEPARTMENT OF REVENUE, PO BOX 280909, HARRISBURG PA 17128-0909, send electronically to ra-btftmaltbev@pa.gov or fax to 717-705-8413.
UNITS
OTHER
BARRELS
OTHER
GALLON
INDICATE SIZE
INDICATE SIZE
DESCRIPTION
1/2 PT.
1 PT.
1 QT.
112.1 OZ.
1/8
1/6
1/4
1/2
CAN & BOTTLE
CAN & BOTTLE
CAN & BOTTLE
TO
7 OZ. TO 8 OZ.
8.1 OZ. TO 16 OZ.
16.1 OZ. TO 32 OZ.
128 OZ.
1. Reporting Month, Beginning Inventory
Purchased from Pennsylvania Manufacturers
2.
(Schedule A)
Purchased from Importing Distributors
3.
(Schedule B)
Purchased from Out-of-State Manufacturers
4.
(Schedule C, REV-1055)
5. Total (Add Lines 1, 2, 3 & 4)
6. Reporting Month, Ending Inventory
Balance to Account For
7.
(Line 5 minus Line 6)
8. Sales of Malt Beverage
9. Other Removals. Attach Explanation
Total Accounted For (Add Lines 8 & 9)
10. This Total must equal Line 7.
I hereby affirm under penalties prescribed by law that this report, including accompanying schedules, has been examined by me and to the best of my knowledge and belief is a true, correct and complete report.
NAME OF OWNER OR OFFICER
TITLE
SIGNATURE
NAME OF CORPORATION OR REGISTERED TRADE NAME WITH LIQUOR CONTROL BOARD

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