WLD-34-B (1/15) 
 
                                                                                            License No.                         
                                                   MICROBREWERY                                             _______________
                                          MONTHLY REPORT OF EXCISE 
                                                              TAX 
                                                               
        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 along with 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: