Form Bt-612 - Refund Claim Of Tax On Fermented Malt Beverages Sold To The Armed Forces Of The United States

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BT-612: REFUND CLAIM OF TAX
ON FERMENTED MALT BEVERAGES
SOLD TO THE ARMED FORCES OF THE UNITED STATES
Read instructions before completing form.
Name of Claimant
Wisconsin Tax Account Number
FEIN/SSN
Mailing Address - Street or PO Box Number
City
State
Zip Code
In accordance with sec. 139.10, Wis. Stats. and chapter 7, Wis. Admin. Code, application is being made for a refund of the
Wisconsin beverage tax paid on fermented malt beverages which have been sold to the armed forces of the United States.
(A)
(B)
(C)
(D)
(E)
Invoice
Kegs
Cases
Tax Refund
(B + C) x D
(in barrels)
(in barrels)
Tax Rate
Date
Number
1
$2.00
2
$2.00
3
$2.00
4
$2.00
5
$2.00
6
$2.00
7
$2.00
8
$2.00
$2.00
9
10
$2.00
11
$2.00
12
$2.00
TOTAL REFUND
13
$
DECLARATION: I declare under penalties of law that the fermented malt beverages upon which the tax was paid and a refund is
now being claimed were sold to the Armed Forces of the United States.
Claimant’s Name
Title
Signature
Date
Business Telephone Number
Email Address
(
)
BT-612 (R. 10-13)
Wisconsin Department of Revenue

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