Claim For Refund Of Tax On Beer On Reservations {389}

389 FORM CLAIM FOR REFUND OF TAX ON BEER DELIVERED AND CONSUMED ON FEDERAL RESERVATIONS (Claim must be filed within 90 days from Date of Purchase.) In accordance with the provisions of the Tax General Article of the Annotated Code of Maryland, I hereby make application for refund in the amount of $______________ to cover Maryland Tax paid by me on _________________ gallons of beer at $.09 per gallon purchased during the month of ______________________ 20_____ from the following manufacturers or wholesalers. (List each delivery ticket separately and attach delivery tickets in support of claim. Use additional sheets when necessary.) Insert heading in columns 4-10 such as: 24/7, 32/7, 36/7, 48/7, 24/8, 36/8, 24/10, 12/12, 24/12, 24/16, 12/32 to identify the container size and the number of containers size per case and for kegs indicate size as: 1/4 bbl, 1/2 bbl, etc. Mail to: Comptroller of Maryland, Revenue Administration Division, P.O. Box 2191, Annapolis, MD 21404-2191. (1) Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 I hereby certify and declare under the penalties of perjury that the beer on which refund of Maryland excise tax is claimed was received and consumed on: ________________________________________________________ Federal Reservation ________________________________________________________ Club, Organization or Post Exchange ________________________________________________________ Rank and Signature of Purchasing Officer ________________________________________________________ Address ___________________________________________ Date ___________________________________________ City, State, ZIP code ___________________________________________ Federal Identification Number (2) Number (3) Name and Address of Maryland Manufacturer or Wholesaler (4) (5) (6) (7) (8) (9) (10) Delivery Ticket COM/RAD-389 American LegalNet, Inc. www.FormsWorkFlow.com 389 (1) Date 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 FORM CLAIM FOR REFUND OF TAX ON BEER DELIVERED AND CONSUMED ON FEDERAL RESERVATIONS page 2 (2) Number (3) Name and Address of Maryland Manufacturer or Wholesaler Brought Forward (4) (5) (6) (7) (8) (9) (10) Delivery Ticket Total Cases/Kegs Reduce to Gallons - See Sample Conversion table below Grand Total Gallons Rate of Tax: $.09 per Gallon Amount of Refund Claim ___________________________ ___________________________ $ __________________________ Case to Gallonage Table (Gallonage per Case) 24/7 1.3125 32/7 1.75 36/7 1.969 48/7 2.625 24/8 1.50 24/10 1.875 12/12 1.125 24/12 2.25 30/12 2.8125 24/16 3.00 12/25 2.34375 12/32 3.00 4/5 liter 5.28 1/4 bbl 7.75 1/2 bbl 15.50 50L keg (13.2) 13.20 COM/RAD-389 American LegalNet, Inc. www.FormsWorkFlow.com