Form Abc-219 - Distributors' Monthly Report Of Sales Page 3
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3KANSAS DEPARTMENT OF REVENUE
MONTH: ________________________
ALCOHOLIC BEVERAGE CONTROL DIVISION
915 SW HARRISON
YEAR: __________________________
TOPEKA, KANSAS 66625-3512
785-296-7015
FEIN:
_________________________
DISTRIBUTORS’ MONTHLY REPORT OF SALES
DISTRIBUTOR NAME: _______________________________________________________________________________________ PHONE: ________________________
ADDRESS: _____________________________________________________ CITY: _______________________________
KS
ZIP CODE: ______________________
CONTACT PERSON: ______________________________________________ EMAIL ADDRESS: __________________________________________________________
I do not have any sales to report this month.
Shipment
Product
Buyer’s License /
Invoice
Invoice
GTIN/SCC
Selling
Product
Unit of
Shipment
No.
Code
UNIMERC
Unit of
Unit Price
Type
Permit Number
Number
Date
(Optional)
Units
Unit Size
Measure
Quantity
Measure
1
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3
4
5
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7
8
9
10
11
12
I declare under penalties of perjury that to the best of my knowledge and belief this is a true, correct and complete return.
SIGNATURE ____________________________________________ TITLE __________________________________________________
State whether individual owner, member of firm, or title if officer of corporation.
ABC-219 (Rev. 7.1.11)
Page 1 of _____
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