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Form #6 Revised 07.08.2024 Dawson County Alcohol Licensing 25 Justice Way, Suite 2223 I [PHONE REDACTED] CONSUMPTION ON PREMISES: ALCOHOL BY THE DRINK DISTILLED SPIRITS EXCISE TAX REPORT & FOOD SALES REPORT Period Reported: Business Name: Address: City, State, Zip Code: County License State License 1. Gross Food Receipts for the month 2. Gross Alcohol Receipts for the month (Beer, Wine, Distilled Spirits) 3. Gross Alcohol Receipts for the month (Beer & Wine Only) 4. Gross Taxable Receipts for the month (Distilled Spirits Only) 5. Three Percent Tax due on Gross Distilled Spirits Receipts 6. On-time Credit (deduct 3% of first $3,000 of line 6 and ½ % of amount in excess of $3,000 on line 6) if postmarked on or before the 10th day of the succeeding month. - 7. Late Payment (add 10% penalty of line 6 if postmarked after the 20th day of the succeeding month. + 8. NET TAX ON DITILLED SPIRITS: = ---PAGE BREAK--- Form #6 Revised 07.08.2024 In order to ensure compliance with the relevant state regulations, please list NEW wholesalers from which the business has procured alcoholic beverages, in accordance with Georgia state law, Rule 560-2-3-. 08 Retailer Purchase from Licensed Wholesaler Excise Tax payments on Distilled Spirits are required under Article III of the Dawson County Consolidated Alcohol Ordinance. • I understand that a penalty of 10% of the tax amount is due for failure to remit tax on or before the 20th of the succeeding month. • I understand that if the Alcohol Licensing Administrator deems it necessary to conduct an audit of the records and books of the licensee, they will notify the licensee of the date, time, and place of the audit. • I understand that any licensee who violates any provision of this article may, upon conviction, be punished by a fine of not less than $300.00, and the license of such location may be suspended or revoked. • I further understand that if my establishment fails to meet the appropriate percentage requirement for the sale of food my license shall be subject to possible suspension or revocation. I HEREBY CERTIFY THAT THE STATEMENTS MADE HEREIN AND IN ANY SUPPORTING SCHEDULES ARE TRUE, CORRECT, AND COMPLETE TO THE BEST OF MY KNOWLEDGE. Signature of Preparer Title Date Printed Name of Preparer Email Address Telephone # Make check payable to Dawson County – Hand-deliver or mail to: Dawson County Alcohol Licensing, 25 Justice Way, Suite 2223, Dawsonville, GA 30534 ***ALL ALCOHOL LICENSEES MUST COMPLETE THIS FORM; HOWEVER, EXCISE TAX IS PAID ONLY ON DISTILLED SPIRITS*** Wholesaler’s Name Phone Number