Form 500 - Alcoholic Beverage Excise Tax Return
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DEPARTMENT USE ONLY
Alaska
ENV
500
Alcoholic Beverage Excise
FSN
Tax Return
Due Date: This return must be filed and the tax paid on or before the last day of each calendar month following the month the alcohol was sold or
consigned into Alaska or removed from a licensed bonded warehouse in Alaska. Submit one return for each licensed facility.
Required Attachments. Attach the original copies of all applicable schedules (B,C,D,E and F) and the inventory report (Schedule G)
For the Month of
EIN
Year
SSN
Individual or Corporation Name
DOR License Number
Check if amended return
Check if zero return
Business Name
Telephone Number
Fax Number
Mailing Address
Contact Person
Title
City
State
Zip Code
Email Address
:
Schedule A Tax Calculation
Enter the information requested below from Schedule B.
1. GALLONS OF LIQUOR
District 1
District 2
District 3
District 4
Total
a
Taxable Gallons
b
Tax Rate
12.80
c
Total Tax (multiply taxable gallons by tax rate)
2. GALLONS OF WINE
Total
a
Taxable Gallons
b
Tax Rate
2.50
c
Total Tax (multiply taxable gallons by tax rate)
3. GALLONS OF BEER, MALT BEVERAGES & CIDER
Total
a
Taxable Gallons
1.07
b
Tax Rate
Total Tax (multiply taxable gallons by tax rate)
c
4. GALLONS OF BEER & MALT BEVERAGES QUALIFYING FOR REDUCED RATE OF TAX (see instructions)
Total
a
Taxable Gallons
b
Tax Rate
0.35
c
Total Tax (multiply taxable gallons by tax rate)
5. IF AMENDED, PREVIOUS AMOUNT PAID
6. TOTAL ALCOHOLIC BEVERAGE TAX DUE (add lines 1c through 4c less line 5)
Payment Information
Note: If your liability is $100,000 or more, you must pay using the Online Tax Information System (OTIS) at or by wire transfer.
Check if you are remitting by:
OTIS confirmation #
Wire transfer date
I declare under penalty of perjury that the information provided in this return, including accompanying schedules and statements, has
been reviewed by me and to the best of my knowledge and belief is true, correct, and complete.
Signature
Printed Name
Date
File and Pay online at
Department Use Only PMD
Validation
500
Mail to: Alaska Department of Revenue, PO Box 110420, Juneau AK 99811-0420
0405-500 Rev 09/12 - page 1
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