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SCHEDULE OF DISTILLED SPIRITS RETURNED BY KENTUCKY WHOLESALERS AND RETAILERS/CONSUMERS
Name of Wholesaler or Retailer/Consumer Date Returned Number of Cases
3 Gal. 2.4 Gal. 12 Liters 10.5 Liters 9.6 Liters 9 Liters 1 Gallon Other (specify)
Make check(s) payable to Kentucky State Treasurer.
Mail report and check(s) to: Excise Tax Section, Department of Revenue, Frankfort, Kentucky 40619
I, the undersigned, a principal officer of the above-named licensee, certify that I have examined this report and it is, to the best of my knowledge and belief, a true, correct and complete report.
Signature
Title
Date