COM/RAD 034-10 05/20
Wholesale licensees must maintain individual request and disposition documentation for all samples used. This documentation is
subject to audit. Documentation must include: numbered ticket, date of disposition, donee’s name and address, brand and quantity
(case/bottles) with appropriate gallonage for wine and distilled spirits, reason (appropriate letter from above list), signatures of
person authorizing and person receiving samples, and any other pertinent data.
Note: Submit original to Alcohol Tax Oce. Keep a copy of this form for your records.
Report Schedule Page of
License Number Period End Date (MM/YYYY)
G-6
DISTILLED SPIRITS
Size 1.75L 1L 750ml 500ml 375ml 200ml 100ml 50ml Gallons
Cases
Bottles
Total Distilled Spirits
WINE
Size 4L 3L 1.5L 1L 750ml 375ml 187ml 100ml Gallons
Cases
Bottles
Total Wine
Purpose Reason Total Wine Total Distilled Spirits
A Samples of alcoholic beverages to licensed retailers
1. Removed by wholesaler representatives .................. __________________ _________________
2. Removed by supplier representatives .................... __________________ _________________
B Donated product
1. Charitable organizations .............................. __________________ _________________
2. Other non-prot organizations ......................... __________________ _________________
3. Alcoholic Beverages Trade associations ................... __________________ _________________
C Sample product to authorized alcoholic beverage experts ..... ________________ _______________
D Samplestoocers,ocials,employeesofwholesalers
1. Personal use ...................................... __________________ _________________
2. Business use ...................................... __________________ _________________
Total ________________ _______________
REPORT OF WINE AND
DISTILLED SPIRITS
SAMPLES
MARYLAND
FORM
034-10
