Form Att-122 - Malt Beverage Excise Tax Monthly Report To Counties And Municipalities

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ATT-122 (REV 1/13)
Georgia Department of Revenue
Alcohol and Tobacco Division
Telephone: (404) 417-4900
E-mail:
ATDIV@dor.ga.gov
MALT BEVERAGE EXCISE TAX MONTHLY REPORT TO COUNTIES AND MUNICIPALITIES
Submit online at
https://gtc.dor.ga.gov
INSTRUCTIONS
1. This report is to be made out in triplicate:
(a)
Original copy to be submitted to county or municipality, along with proper tax remittance (b) one copy to be submitted
online to the Georgia Department of Revenue, along with report ATT - 123. (c) One copy to remain on file in Wholesale
Distributor’s licensed place of business.
TO: THE TAKING AUTHORITY SHOWN BELOW
FROM: WHOLESALE DISTRIBUTOR SHOWN BELOW
CITY OF
TRADE NAME
or
STREET ADDRESS
COUNTY OF
CITY
STATE
ZIP CODE
this is to certify that the following quantities of malt beverages are sold and delivered within your taxing jurisdiction during the month of
___________________, 20____ and attached hereto is remittance for all taxes thereon.
OUNCES OR BARREL
NUMBER OF OUNCES OR
TAX RATE
TOTAL TAX DUE (COL. 2 x Col. 3)
SIZE
BARRELS
(3)
(4)
(1)
(2)
(A)
Ounces
@
$
Per Ounce
=
(B)
Barrels
@
$
Per Barrel
=
GRAND TOTAL TAX DUE (Total of Column 4, Lines A-B) ..................................................
=
(REMIT HEREWITH)
I certify under penalty of law, this is a true and correct report of Malt Beverages sold and delivered within your Taxing Jurisdiction for
the Month of ___________________, 20 ____.
______________________________________
____________________________________________
(SIGNATURE)
(TITLE)

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