Form Ab-Ds - Alcoholic Beverages Excise Return Direct Shipments To Massachusetts

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Rev. 10/06

Form AB-DS

Massachusetts

Alcoholic Beverages Excise Return

Department of

Direct Shipments to Massachusetts

Revenue

Under Massachusetts General Laws, Ch. 138, sec. 21, as amended. For the month of

Name of licensee

License number

Federal Identification number

Telephone

Street address

City/Town

State

Zip

Computation of Excise.

Before entering below, complete all schedules on pages 2 and 3.

Total from

Excise

Schedules A–D

Schedules E–H

Total

Rate of

Multiply

col. c × col. d

Type of beverage

(from pg. 2)

(from pg. 3)

Add col’s. a + b

excise

1 Still wine, other than cider containing more than

3% but not more than 6% of alcohol, including

vermouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

$0.55

2 Champagne and all other sparkling wine . . . . . . . 2

$0.70

3 Alcoholic beverages other than malt beverages

containing 15% or less of alcohol by volume

at 60°F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

$1.10

4 Alcoholic beverages containing more than 15%

but not more than 50% of alcohol by volume

at 60°F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

$4.05

5 Total excise. Add lines 1 through 4. Pay in full with this return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5

This return with full payment is due on or before the 20th day of the month following the month indicated above. Payments not received by the due date

are considered late unless they were postmarked at a U.S. post office at least two days prior to the due date. A penalty of 1% per month (or fraction there-

of) of the unpaid balance, up to a maximum of 25%, is assessed for the late filing of this return. Any portion of the tax not paid by the due date is subject

to a penalty of

% per month (or fraction thereof) up to a maximum of 25% and interest charges. Make check payable to: Commonwealth of Massa-

⁄

chusetts. Mail to: Massachusetts Department of Revenue, PO Box 7012, Boston, MA 02204.

Declaration

Under the penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best

of my knowledge and belief it is true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which

he/she has knowledge.

Name of winery

Signature

Date

200 9/10 CPSERV3195OSD2011001