Cered Inventory — Wine and Cider
Sign Here
Adavit
I declare, under penales of perjury and evasion, that I am familiar with the books, papers and records of the business from which this
report was prepared, that this report has been examined by me and, to the best of my knowledge and belief, is true, correct and complete.
Must be signed and cered by an ocer or owner.
Authorized Signature Date Dayme Phone
Print Name Title
Signature of Department Representave (oponal) Print Name of Department Representave Title
Mail to: Minnesota Revenue, Mail Staon 3331, St. Paul, MN 55146-3331
Phone: 651-556-3036 Fax: 651-556-5236 Email: alc.taxes@state.mn.us
(Rev. 2/12)
A B
Liters Boles
1 Wine, 14% or less ................................... 1
2 Wine, more than 14% to 21% .......................... 2
3 Wine, more than 21% to 24% .......................... 3
4 Wine, more than 24% ................................ 4
5 Sparkling wine ...................................... 5
6 Cider .............................................. 6
Total Inventory
Check if Amended
Company Name FEIN
Address Minnesota Tax ID Number Locaon Code
City State ZIP Period of Return
Print or Type
LB1
