Annual Gallonage Tax Return And Sales Report (Page 3 of 3) in pdf

Annual Gallonage Tax Return And Sales Report Page 3

Kansas Department of Revenue

Alcoholic Beverage Control Division

915 S.W. Harrison Street, Room 214

Topeka, KS 66625-3512

Phone: 785-296-7015 Fax: 785-296-7185

KANSAS SPECIAL ORDER SHIPPING

ANNUAL GALLONAGE TAX RETURN AND SALES REPORT

LICENSE NUMBER:

-___ ___ ___-___ ___ ___ ___-___ ___

YEAR: _________________

FEIN: _________________

DBA Name:

_____________________________________________________________ CONTACT PERSON: __________________________________________

PHONE: _________________________________________________________________ E-MAIL ADDRESS: __________________________________________

I have no shipments to Kansas consumers this year.

Gallons Shipped:

Shipment

Zip

Quantity

Size

Order

Customer Name

Address

City

Date

Code

Shipped

Total

Fortified

Light

Wine

I declare under penalties of perjury that to the best of my knowledge and belief this is a true, correct and complete report.

SIGNATURE ____________________________________________ DATE ____________________________________________

Page ___ of ___

ABC-1040 (Rev. 7.1.11)

Annual Gallonage Tax Return And Sales Report Page 3