Form Abc-217 - Distributors' Monthly Report Of Purchases Page 2
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2KANSAS DEPARTMENT OF REVENUE
MONTH: ________________________
ALCOHOLIC BEVERAGE CONTROL DIVISION
915 SW HARRISON
YEAR:
________________________
TOPEKA, KANSAS 66625-3512
PHONE: 785-296-7015
FEIN:
_________________________
DISTRIBUTORS’ MONTHLY REPORT OF PURCHASES
DISTRIBUTOR NAME: ______________________________________________________________________________________ PHONE: _________________________
ADDRESS: _____________________________________________________ CITY: _______________________________ KS
ZIP CODE: ______________________
CONTACT PERSON: ______________________________________________ EMAIL ADDRESS: __________________________________________________________
I do not have any purchases to report this month.
Vendor’s Kansas
Purchase
Purchase
Product
GTIN/SCC
Selling
Product
Unit of
Received
Received Unit
Supplier Permit, Farm
Order
Order
No.
Code
UNIMERC
Type
Winery or Microbrewery
Received
Received
Units
Unit Size
Measure
Quantity
of Measure
(Optional)
License Number
Number
Date
1
2
3
4
5
6
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-217 (7.1.11)
Page 1 of ____
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