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File with the Department of Revenue on or before the 20th of the month following the month for which the report is made.


<table border=1 style='margin: auto; word-wrap: break-word;'><tr><td colspan="4">Name and Address of Distiller, Rectifier or Bottler</td><td colspan="4">Revenue Account Number ________\nState License Number ________\nReport for Month of _______, 20______</td></tr><tr><td rowspan="2">Part I—Distilled Spirits\nExcise Tax Report</td><td colspan="7">Number of Cases</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>3 Gal.</td><td style='text-align: center; word-wrap: break-word;'>2.4 Gal.</td><td style='text-align: center; word-wrap: break-word;'>12 Liters</td><td style='text-align: center; word-wrap: break-word;'>10.5 Liters</td><td style='text-align: center; word-wrap: break-word;'>9.6 Liters</td><td style='text-align: center; word-wrap: break-word;'>9 Liters</td><td style='text-align: center; word-wrap: break-word;'>1 Gallon\nOther (specify)</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>1. Gift Shop or other retail outlet\nsales to consumers and retailers\nin Kentucky (per instructions).................................................</td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>2. Samples taken from\nKentucky inventory.........................................................</td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>3. Other (per instructions).................................................</td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>4. Total subject to excise tax\n(add lines 1, 2 and 3).................................................</td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>5. Less quantities returned by\nretailers and consumers\n(complete schedule on reverse side) ..</td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>6. Balance subject to excise tax\n(line 4 minus line 5).................................................</td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>7. Tax rate per case.................................................</td><td style='text-align: center; word-wrap: break-word;'>$ 5.76</td><td style='text-align: center; word-wrap: break-word;'>$ 4.61</td><td style='text-align: center; word-wrap: break-word;'>$ 6.09</td><td style='text-align: center; word-wrap: break-word;'>$ 5.33</td><td style='text-align: center; word-wrap: break-word;'>$ 4.87</td><td style='text-align: center; word-wrap: break-word;'>$ 4.57</td><td style='text-align: center; word-wrap: break-word;'>1.92 < /td > < /tr > < tr > < td style = 'text-align: center; word-wrap: break-word;' > 8. Excise tax applicablen(line 6 multiplied by line 7)................................................. < /td > < td style = 'text-align: center; word-wrap: break-word;' > $</td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'>$ $</td><td style='text-align: center; word-wrap: break-word;'>$ $</td><td style='text-align: center; word-wrap: break-word;'>$ $</td><td style='text-align: center; word-wrap: break-word;'>$ $</td><td style='text-align: center; word-wrap: break-word;'>$ $</td></tr><tr><td colspan="6">9. Total excise tax due (total of all items on line 8).................................................</td><td style='text-align: center; word-wrap: break-word;'>20</td><td style='text-align: center; word-wrap: break-word;'>$</td></tr><tr><td colspan="6">10. Penalty and interest due (per instructions).................................................</td><td style='text-align: center; word-wrap: break-word;'>$ $</td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td colspan="6">11. Total amount due (add lines 9 and 10).................................................</td><td style='text-align: center; word-wrap: break-word;'>$ $</td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td colspan="8">☐ Check the box if Tax Type 20 Excise Tax was paid online. (Payment ID# _______ )</td></tr><tr><td colspan="8">Part II—Distilled Spirits Wholesale Sales Tax Report</td></tr><tr><td colspan="6">12. Gross receipts from wholesale sales of spirits to consumers and retailers in Kentucky (excluding 11% wholesale sales tax).................................................</td><td style='text-align: center; word-wrap: break-word;'>$ $</td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td colspan="6">13. Total wholesale sales tax due (line 12 multiplied by .11).................................................</td><td style='text-align: center; word-wrap: break-word;'>22</td><td style='text-align: center; word-wrap: break-word;'>$</td></tr><tr><td colspan="6">14. Penalty and interest due (per instructions).................................................</td><td style='text-align: center; word-wrap: break-word;'>$ $</td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td colspan="6">15. Total amount due (add lines 13 and 14).................................................</td><td style='text-align: center; word-wrap: break-word;'>$ < /td > < td style = 'text-align: center; word-wrap: break-word;' > < /td > < /tr > < tr > < td colspan = "8" > ☐ Check the box if Tax Type 22 Wholesale Sales Tax was paid online. (Payment ID# _______) < /td > < /tr > < tr > < td colspan = "8" > Part III—Distilled Spirits Case Sales Tax Report (Note: This Part applies to self-distributed sales by Class Bdistillers only) < /td > < /tr > < tr > < td colspan = "6" > 16. Cases subject to tax (total number of cases included in line 1 of Part Iabove self-distributed by Class Bdistillers)................................................. < /td > < td style = 'text-align: center; word-wrap: break-word;' > $</td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td colspan="6">17. Total case sales tax due (line 16 multiplied by .05).................................................</td><td style='text-align: center; word-wrap: break-word;'>19</td><td style='text-align: center; word-wrap: break-word;'>$</td></tr><tr><td colspan="8">☐ Check the box if Tax Type 19 Distilled Spirits Case Sales Tax was paid online. (Payment ID# _______ )</td></tr><tr><td colspan="8">Part IV—Total Amount Due with Monthly Report of Distillers, Rectifiers or Bottlers</td></tr><tr><td colspan="6">18. Total distilled spirits excise, wholesale sales, and case sales tax due (add lines 11, 15, and 17).................................................</td><td style='text-align: center; word-wrap: break-word;'>$ $</td><td style='text-align: center; word-wrap: break-word;'></td></tr></table>

===== PAGE 2 =====

<table border=1 style='margin: auto; word-wrap: break-word;'><tr><td colspan="10">SCHEDULE OF DISTILLED SPIRITS RETURNED BY KENTUCKY WHOLESALERS AND RETAILERS/CONSUMERS</td></tr><tr><td rowspan="2">Name of Wholesaler or Retailer/Consumer</td><td rowspan="2">Date Returned</td><td colspan="8">Number of Cases</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>3 Gal.</td><td style='text-align: center; word-wrap: break-word;'>2.4 Gal.</td><td style='text-align: center; word-wrap: break-word;'>12 Liters</td><td style='text-align: center; word-wrap: break-word;'>10.5 Liters</td><td style='text-align: center; word-wrap: break-word;'>9.6 Liters</td><td style='text-align: center; word-wrap: break-word;'>9 Liters</td><td style='text-align: center; word-wrap: break-word;'>1 Gallon</td><td style='text-align: center; word-wrap: break-word;'>Other (specify)</td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; 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word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr></table>

## IMPORTANT NOTICE

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.

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