Form Lb1 - Certified Inventory - Wine And Cider
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1LB1
Certified Inventory — Wine and Cider
Check if amended
Company name
FEIN
Address
Minnesota tax ID number
Location code
City
State
Zip
Period of return
A
B
Liters
Bottles
1 Wine, 14% or less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Wine, more than 14% to 21% . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Wine, more than 21% to 24%. . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Wine, more than 24% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Sparkling wine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Cider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Affidavit
I declare, under penalties of perjury and evasion, that I am familiar with the books, papers and records of the business from which
this report was prepared, that this report has been examined by me and, to the best of my knowledge and belief, is true, correct and
complete.
Must be signed and certified by an officer or owner.
Authorized signature
Date
Daytime phone
Print name
Title
Signature of department representative (optional)
Print name of department representative
Title
Mail to: Minnesota Revenue, Mail Station 3331, St. Paul, MN 55146-3331
Phone: 651-556-3036 TTY: 711 Minnesota Relay Fax: 651-556-5236 Email: alc.taxes@state.mn.us
(Rev. 2/12)
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Parent category: Financial