Form Rev-1014 - Distributor'S Monthly Report Page 2
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1
2REV-1014 AS+ (04-12)
BUREAU OF BUSINESS TRUST FUND TAXES
SCHEDULE A
MISCELLANEOUS TAX DIVISION
MALT BEVERAGE PURCHASED FROM
PO BOX 280909
PENNSYLVANIA MANUFACTURES
HARRISBURG PA 17128-0909
Print or Type
BUSINESS NAME
REPORTING MONTH/YEAR
EIN
LICENSE NUMBER
LID NUMBER
UNITS
OTHER
BARRELS
OTHER
GALLON
INDICATE SIZE
INDICATE SIZE
NAME AND ADDRESS OF MANUFACTURES
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.
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
TOTALS
SCHEDULE B
NAME AND ADDRESS OF
IMPORTING DISTRIBUTORS
MALT BEVERAGE PURCHASED FROM IMPORTING DISTRIBUTORS
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
NAME
STREET
CITY
STATE
ZIP CODE
TOTALS
If additional space is needed, attach facsimiles of these schedules or additional 8 1/2" x 11" sheets.
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