Form Alc-1570 - Affidavit Of Breakage And Destruction

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ALC-1570
Oklahoma Tax Commission
September 2011
Alcohol and Tobacco Section
Affidavit of Breakage and Destruction
State of: ____________________________________
County of: _________________________________________
I, ____________________________________________ do hereby certify that the beer listed below was destroyed becasue:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Please Check One:
3.2 Beer
Excess of 3.2
24/12
Other
24/16, 12/32
Other
1/2 BBLS
Other
Other
Other
(Convert all package sizes to barrel equivalents and total)
TOTAL BARRELS DESTROYED
Dated this ________________ day of ________________________________ , _________________ .
City of: _____________________________________
Distributor Name: ___________________________________
Signature: ___________________________________________________
Subscribed and sworn to before me this ____________ day of ___________________ , _________ .
My commission expires: ______________________ , _______________ .
Notary Seal
______________________________________________________________________ , Notary Public

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