WLD-34 (2/14) 
                                                                                             
                                                WHOLESALERS                                 License #:________________

                                                MONTHLY REPORT 

                                                       OF EXCISE 
                  
  6601 Campstool Road                                  TAX 
  Cheyenne, Wyoming 82002-0110 
   
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                Regulations require report and payment due no later than the 15  day of the month followingth            purchases. 
                NOTE: Zero Purchase Reports are also required to be submitted no later than the 15  day of the month. 
       Mail this form along with payment to: WYOMING LIQUOR DIVISION, 6601 Campstool Road, Cheyenne, WY 82002-0110 
                                                               
   Report of Malt Beverage products imported into Wyoming from out of state breweries or wholesalers: 
                                                                                                                          
 Wholesaler:                                                                                                             Page              of 
                                                                              
 DBA:                                                                        Month:                                      Year:                           
  Address (P.O. Box, Street, City, State, Zip):                                              Phone Number:  
                                                                                              
                                                                                                                          GALLONS 
   DATE                       PURCHASED  FROM:                                INVOICE NUMBER                              (Nearest Hundredth) 
                                                                                                                          
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                Total Gallons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                     .       
                                                                                                                          
                Tax per Gallon ($ .005 per liter) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .           X                 .019 
                                                                                                                          
                Tax Due this page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                          .       
                                                                                                                          
                +/- Previous Page or last month Adjustment. . . . . . . . . . . . . . . . . . . . . .                                        .       
                                                                                                                          
                Total Tax Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                      .       
  
 I do solemnly swear that the foregoing is a true and correct statement of all beer manufactured or imported into the state during the month for which this report 
 is rendered, to the best of my knowledge and belief. 
 Date Signed:   Printed Name:                                                Signature: