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WLD-34 (2/14)
WHOLESALERS License #:________________
MONTHLY REPORT
OF EXCISE
6601 Campstool Road TAX
Cheyenne, Wyoming 82002-0110
th
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: