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Form #7 Revised 05.13.2014 Dawson County Planning & Development 25 Justice Way, Suite 2322, Dawsonville, GA 30534 (706) 344-3500 ext. 42335 WHOLESALER’S REPORT: DISTILLED SPIRITS & WINE SALES Business Name: Address: City, State, Zip Code: This is a report to the Planning & Development Department of Dawson County of all deliveries of wine and distilled spirits sold in the unincorporated areas of Dawson County, Georgia and collections of special fees imposed upon retail sales for the month of , 20 . DISTILLED SPIRITS: 1. liters sold @ $.22 per liter = 2. * Less 3% discount of line 1 = 3. Total = WINE: 1. liters sold @ $.22 per liter = 2. * Less 3% discount of line 1 = 3. Total = Add 10% penalty = (If remitted after the 20th day of the succeeding month.) GRAND TOTAL TAX REMITTED: On sheets attached hereto is listed the quantity delivered, the name and address of business concern or person to whom delivered for the month. I CERTIFY, under penalty of perjury, that this is a true and correct report of all wine and distilled spirits sold and delivered in the unincorporated areas of Dawson County, Georgia, during the month shown on this report and that we have collected the fees shown above at the time of delivery and the purchaser was furnished a true and correct invoice for said beverages. Signature of Preparer Title Date Name of Preparer Telephone # of Preparer