WLD-34 (2/2014) 
   
                                                                                      MATTHEW H. MEAD 
                                                                                      Governor 
                                                 WHOLESALERS                          DANIEL W. NOBLE 
                                                MONTHLY REPORT OF EXCISE              Director 
                                                                                      GREG COOK 
                                                 TAX                                  Administrator 
                                                                                      Phone:                                (307) 777-7231 
                                License No.__________________________                 Fax:                                  (307) 777-6255 
                                                  
                                                                                      Website: http://eliquor.wyoming.gov 
                                                                                      
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              Regulations require report and payment due no later than the 15  day of the month following purchases. 
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                  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: