Note: Incomplete forms will be returned to you to be fully completed.
Business Name:
Business Address:
Monthly/Year Reported:
Email:
City/State Alc. License No:
A. INVENTORY REPORTING LIQUOR ONLY
List your inventory purchases of distilled spirits from licensed
wholesaler for monthly period reported.
Liters
1. Gross Distilled Spirits by the Drink:
2. Tax – 3% of line 1:
3. Brewery Excise. $6.00 per ½ barrel;
$12.00 per barrel (15 1/2 gallons = ½
barrel; 31 Gallons = barrel)
4. Less 3 % of Line 2 and 3 ONLY on
timely returns (by 20
th
of the month)
5. Penalty – 15% times line 2 and 3:
6. Interest- .542% per month
7. Total Payment Amount Due:
C. Gross Sales for the Month
1. Artisan Beverages of GA
2. United Distributors
3. Eagle Rock Distributing
4. GA Crown Distributing
5. National Distributing
6. General Wholesale Co.
7. Empire Distributors
8. ______________________
9. ______________________
10. ______________________
11. Total Liters Purchased:
12. Beginning Inventory:
1. Food & nonalcoholic beverage:
2. Alcoholic Beverage Sales:
(Beer, Wine & Liquor)
3. Other revenue:
(cover charge, parking, hookah, etc)
4. Total Sales:
Remit on or before the 20th day of the succeeding month. 15% penalty on all payments received after the 20th day of
the month. See Section 6-240 of the City of Chamblee Alcoholic Beverage Ordinance.
I hereby certify that the statements made herein and in any supporting schedules are true, correct, and complete to the best
of my knowledge.
PLEASE MAKE A COPY FOR YOUR FILE AND RETURN THE ORIGINAL WITH YOUR PAYMENT.
Please return this form with remittance to:
City of Chamblee
Attn: Occupation & Licensing Officer
5468 Peachtree Road
Chamblee, GA 30341
Make Check Payable to:
City of Chamblee
