Form Bt-605 - Refund Claim For Fermented Malt Beverage Tax

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BT-605 – REFUND CLAIM FOR FERMENTED MALT BEVERAGE TAX
Read instructions before completing.
Legal Name
Business Name (DBA)
Tax Account Number
Mailing Address (where check should be sent)
City
State
Zip Code
PART 1 – DESCRIPTION OF SPOILED BEVERAGES AND REFUND COMPUTATION
A
B
C
Line
Brand
Number of Barrels
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Sub Total (add lines 1 through 13)
15
Total Number of Barrels From Any Additional Attached Sheets
16
Total Number of Barrels (add lines 14 and 15)
17
Tax Rate
$2.00
X
18
Total Refund Amount (multiply line 16 by line 17)
$
If necessary, attach additional sheets to list the Fermented Malt Beverages included in this claim.
PART 2 – CLAIMANT’S DECLARATION
I declare under penalties of law that the fermented malt beverages listed above are spoiled and unfit for consumption; that the
above information is true, correct and complete to the best of my knowledge and belief.
I swear that all the fermented malt beverages listed above were destroyed in my presence on
.
Name
Title
Date
Signature
Business Telephone Number
(
)
BT-605 (R. 11-13)
Wisconsin Department of Revenue

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