Indiana Department of Revenue
Beer Wholesaler’s Excise Tax Report
Form 810
(Formerly schedule D)
Reporting Month ________________ Year________________
State Form 46998
(R2 / 3-09)
Name (As Appears on Permit)
Federal I.D. Number
Mailing Address
City
State
Zip Code
State Beer Permit Number
►
◄
The report is due on or before the 20th day of the month following the month being reported.
Gallons
1.
Total Gallons Received per Schedule B-1 .............................................................................
1
2.
Deduct total Gallons per Schedule B-2 .................................................................................
2
3.
Deduct total Gallons per Schedule B-3 .................................................................................
3
4.
Total Deductions (Line 2 + Line 3) .......................................................................................
4
5.
Gallons subject to Tax (Line 1 minus Line 4) ....................................................................
5
Tax
6.
Multiply Line 5 by Tax Rate of .115 ......................................................................................
6
Discount (Line 6 x .015) if timely filed .................................................................................
7.
7
8.
Amount Due (Line 6 Minus Line 7) ......................................................................................
8
9.
Adjustments Auth. @ Department of Revenue (Money Only) ............................................
9
If return is filed after due date, Add 10% of Line 8 (x.10) or $5.00 whichever is greater.
10.
(Penalty is $5.00 if return is filed late without tax due) .........................................................
10
If return is filed late add interest ............................................................................................
11.
11
12.
Total Amount Due (Line 8 + or - Line 9 + Line 10 + Line 11) Enclose your payment
for this amount .......................................................................................................................
12
Discount (Line 7) does not apply unless the report and payment is timely filed.
I hereby certify, under penalty of perjury, that the information contained herein, and on supporting documents is to the best
of my knowledge true and correct.
__________________________________________________________________________________________________________
Signature of Agent or Officer
Title
__________________________________________________________________________________________________________
Date
Telephone Number
Mail To: Indiana Department of Revenue, P.o. Box 6114, Indianapolis, In 46206-6114
Questons related to this form: Call (317) 615-2710