Carriers Alternative Mixed Beverage Tax Return

COMMONWEALTH OF VIRGINIA DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL P. 0. RICHMOND, BOX 27491 VIRGINIA 23261 QUARTER ENDING: ,20 CARRIER'S ALTERNATIVE MIXED BEVERAGE TAX RETURN (Section 4.1-221, Virginia Code) (Submit in triplicate on or before Oct. 30, Jan 30, July 30.) April 30 and REPORTING CARRIER VIRGINIA LICENSE NUMBER Mixed Beverages-No. ********************************* 1. 2. 3. R. P. M.* of system to for quarter for R. (As reported . . to . D. . . 0. . T. . or . I . C. . . C.) . . . . . . . . . . . . : : % R. P. M. allocable Virginia of quarter Proportionate percentage P. M. allocable to Virginia (Item 2 + Item 1): (State . . . gallonage . . . . if . . : 4. Alcoholic beverage purchases f o r s y s t e m f o r q u a r t e r actual number of "minatures" purchased unavailable) . . 5. Alcoholic beverages purchases allocable to Virginia (Item 4. X Item 3.) . . : 6. Carrier's estimate of average number of drinks consumed in Virginia during quarter (Assume 1.7 oz. per drink) . . . . . . . . . . . . . . . . . . . . : 7. Carrier's estimate of tax due Commonwealth (Item 6. X $ . 10) (Do not make remittance *R. P. M. with this report).... . . . . . . . . . . . . . . . . : $ - Revenue passenger miles ********************************* I declare under the penalities provided by law that according to the best of my knowledge and belief: the above information is true and correct (FOR A. B. C. DEPT. USE ONLY) Average Tax number by drinks Board . . fixed . . . by . Board : $ (Person Preparing Return) calculated (Remit within 5 days to Beverage Control") "Department of Alcoholic (Title) Virginia Alcoholic Beverage Control Board DATE: (TITLE) DATE: , 20 . ,20 American LegalNet, Inc. www.FormsWorkflow.com