Athens-Clarke County Alcoholic Beverage Excise Tax Form by PermitDocsPrivate


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                                       ATHENS-CLARKE COUNTY, GEORGIA
                                          DEPARTMENT OF FINANCE
                                              375 STALULA AVE
                                                P O BOX 1748
                                           ATHENS, GEORGIA 30603


Distributor Name:        ________________________________________________________________

Distributor Address:     ________________________________________________________________


This is a report to the Athens-Clarke County Finance Department of all deliveries of alcoholic beverages in
Athens-Clarke County, Georgia (unified Clarke County and City of Athens) for the month of


                         Beer                                              $ ________________________

_________________        Liters of Wine @ 22 cents per liter               $ ________________________

_________________        Liters of Liquor @ 22 cents per liter             $ ________________________

                         (less 3% liquor only)                             $ ________________________

                         TOTAL TAX REMITTED                                $ ________________________

On sheets attached hereto is listed the number of liters delivered, the name and address of business concern
or person to whom delivered for the month.

This report must be signed and mailed no later than the 10th day of the month following the month for which
this report is made. The 3% discount on liquor will not be allowed unless payment is made on time. Make
check payable to Athens-Clarke County, Department of Finance, P O Box 1748, Athens, Georgia 30603.

WE CERTIFY, under penalty of perjury, that this is a true and correct report of all beer, wine, and liquors sold
and delivered in Athens-Clarke County during the month shown above, and that at the time of delivery we
furnished the purchaser with a true and correct invoice for said beverage.

_____________________                             ___________________________________________________
Date                                              Signature of Distributor

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