WLD-34-B (8/19)                                                                           License No.                       
                                                                                                            _______________
                                               MICROBREWERY 

                                          MONTHLY REPORT  

                                                   OF EXCISE 

                                                              TAX 
                                                                
6601 Campstool Road 
Cheyenne, Wyoming 82002-0110                                    
                                                               
        Regulations require report and payment due no later than the 15  daythof the month following production. 
        NOTE: Zero Production Reports are also required to be submitted no later than the 15  day ofththe month. 
  Mail this form with tax payment to: WYOMING LIQUOR DIVISION, 6601 Campstool Road, Cheyenne, WY 82002-0110 
 
 Report of Malt Beverage product(s) produced during:             Month:                               Year: 
  
 Microbrewer:                                                    DBA:  

 Address: 
  
 City, State, Zip:                                                                            Phone Number: 
  
                                                                                                      GALLONS 
                                                                                                  (Nearest Hundredth) 
                                                                                               
 1.    Malt Beverage product(s) produced during month indicated:                                                         . 
                                                                                               
 2.    Total Gallons:                                                                                                    . 
                                                                                                             
                                                        CREDITS 
                                                                                               
 4.    Spoilage:                                                                                                         . 
                                                                                               
 5.     Sales to  OUT OF STATE  Wholesalers (copy of invoice[s] required):                                               . 
                                                                                               
 6.    Total Credits:                                                                                                    . 
  
                                 Total Gallons (Line 2 minus Line 6)................                                     . 
                                                                                               
                              Tax per Gallon ($.005 per liter).......................                        X            .019 
                                                                                               
                            +/- Last month Adjustment..............................                                      . 
                                                                                               
                            Total Tax Due..................................................                              . 
  
 I do solemnly swear that the foregoing is a true and correct statement of all malt beverage products 
 manufactured  in  the  state  during  the  month  for  which  this  report  is  rendered,  to  the  best  of  my 
 knowledge and belief. 

 Date Signed       Printed Name:                                         Signature: