Form Asr - Alcohol Sales On Reservations

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ASR
Alcohol Sales on Reservations
Check if amended
Company name
FEIN
Address
Minnesota tax ID number
Location code
City
State
Zip
Period of return
Beer
Wine
Distilled Spirits
Bottles
More
Less
More Than
More Than
More Than
Sparkling
Cider
Distilled Spirits Low-Alcohol
Wine & Distilled
Name of Tribe
Than 3.2%
Than 3.2%
14% or Less 14% to 21%
21% to 24%
24%
Wine
(liters)
(liters, excluding
Dairy
Miniatures
Spirits
(in barrels)
(in barrels)
(liters)
(liters)
(liters)
(liters)
(liters)
miniatures)
(liters)
(
(200 ml or more)
50 ml)
Bois Forte Band of Chippewa Indians
Fond Du Lac Reservation
Grand Portage Band of Chippewa
Leech Lake Reservation
Lower Sioux Indian Community
Mille Lacs Band Of Ojibwe Indians
Prairie Island Indian Community
Red Lake Band of Chippewa Indians
Shakopee Mdewakanton Sioux
Community
Upper Sioux Indian Community
White Earth Band of Chippewa Indians
Sign here: I declare that this form is correct and complete to the best of my knowledge and belief.
Authorized signature
Print name
Title
Date
Daytime phone
Paid preparer’s signature
PTIN
Date
Daytime phone
Mail to: Minnesota Revenue, Mail Station 3331, St. Paul, MN 55146-3331
Phone: 651-556-3036 TTY: 711 for Minnesota Relay Fax: 651-556-5236 Email: alc.taxes@state.mn.us
(Rev. 12/12)

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