A
LCOHOLIC BEVERAGE CONTROL
109 SW 9
th
STREET
P.O. BOX 3506
T
OPEKA KS 66601-3506
ABC-836 (Rev. 07/18)
STATE OF KANSAS
D
EPARTMENT OF REVENUE
P
HONE: 785-296-7015
F
AX: 785-296-7185
www.ksrevenue.org/abc.html
KANSAS NON-BEVERAGE USER MONTHLY REPORT OF PURCHASES
REPORT PERIOD: Month: Year:
Purchaser DBA Name License Number
Business Mailing Address
City State Zip Code
Person Completing Report E-mail Address
Telephone Number Fax Number
☐ I do not have any purchases to report this month. ☐ Spreadsheet attached*
*You may attach a spreadsheet with column headings that are exactly the same to report your purchase information.
DATE
RECEIVED
PURCHASE
ORDER NUMBER
PURCHASED FROM
NUMBER OF GALLONS
PURCHASED
NAME LICENSE NUMBER** OR ADDRESS
**Enter the license number for purchases from a Kansas Distributor, Farm Winery, Manufacturer, Microbrewery or Microdistillery.
Alcohol Wine
This report must be filed by the 15
th
day of the following month. You are required to file this report even if you have no purchases
to report.
All records shall be maintained for three years and shall be available for inspection by the Director or any agent or employee of
the Director or Secretary upon request. DO NOT SEND INVOICES.
I declare under penalties of perjury that to the best of my knowledge and belief this is a true, correct and complete return.
SIGNATURE TITLE
State whether individual owner, member of firm, or title if officer of corporation.
DATE
click to sign
signature
click to edit
![]()
