FORM
389
CLAIM FOR REFUND OF TAX ON BEER
DELIVERED AND CONSUMED ON FEDERAL
RESERVATIONS
(Claim must be led within 90 days from Date of Purchase.)
In accordance with the provisions of the Tax General Article of the Annotated Code of Maryland, I hereby make application for refund
in the amount of $______________ to cover Maryland Tax paid by me on _________________ gallons of beer at $.09 per gallon
purchased during the month of ______________________ 20_____ from the following manufacturers or wholesalers.
(List each delivery ticket separately and attach delivery tickets in support of claim. Use additional sheets when necessary.)
Insert heading in columns 4-10 such as: 24/7, 32/7, 36/7, 48/7, 24/8, 36/8, 24/10, 12/12, 24/12, 24/16, 12/32 to identify the con-
tainer size and the number of containers size per case and for kegs indicate size as: 1/4 bbl, 1/2 bbl, etc.
Mail to: Comptroller of Maryland, Revenue Administration Division, P.O. Box 2191, Annapolis, MD 21404-2191.
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
Delivery Ticket
Name and Address of Maryland
Manufacturer or Wholesaler
Date Number
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
I hereby certify and declare under the penalties of perjury that the beer on which refund of Maryland excise tax is claimed was re-
ceived and consumed on:
________________________________________________________ ___________________________________________
Federal Reservation Federal Identication Number
________________________________________________________
Club, Organization or Post Exchange
________________________________________________________ ___________________________________________
Rank and Signature of Purchasing Ofcer Date
________________________________________________________ ___________________________________________
Address City, State, ZIP code
COM/RAD-389
