Schedule "M" (Form R-17) - Alcoholic Beverage Transportation

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STATE OF NEW JERSEY

R-17

(9-97, Rev. 2)

Sheet No. ____________ of ____________

DEPARTMENT OF THE TREASURY

DIVISION OF TAXATION

THE DIVISION OF TAXATION, BEVERAGE TAX,

Report for the bimonthly period of

PO BOX 241, TRENTON, NJ

08695-0241,

BEVERAGE TAX

SHOULD BE IMMEDIATELY NOTIFIED IN CASE

_________, and _________, year _______

OF ANY DISCREPANCIES ON THIS REPORT.

ALCOHOLIC BEVERAGE TRANSPORTATION SCHEDULE “M”

List each shipment of Alcoholic Beverages transported from a place in New Jersey to a place outside New Jersey during the bimonthly period by __________________________________

License No. _____________________________________, delivered into the State of ________________________________________

A separate sheet must be prepared for each State into which deliveries were made during the period.

Submit the original and an extra copy of this schedule with your original report. Keep a copy of this schedule attached to your file copy of the report.

Picked up at: Name & Address of

Transferred for Delivery

No. & Kind of

No. & Size of

Date of

Date of Pick-up and

Licensed Premises, Warehouse,

Name & Address of Consignor

Name & Address of Actual Consignee

to Other Transporter

* Kind of

Pkgs., such

Containers,

Delivery

Pro No.

Railroad, Forwarding Company,

(Actual Shipper, Not a Pier,

(Not of Another Transporter,

Beverage

as Bbl.,

12/Qts., 24/Pts.,

Etc.

Ship or Pier

Warehouse, or Transporter)

Pier or Warehouse)

Name and Address of Transporter

Case, etc.

* IN COLUMN HEADED “KIND OF BEVERAGE”, CLASSIFY AS EITHER BEER, LIQUOR, ALCOHOL, STILL WINES, VERMOUTH, SPARKLING WINES. (including apple cider with more than 7% alcohol) or APPLE CIDER (3.2% to 7% alcohol).

(CONTINUE ON REVERSE SIDE)