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Form #6 Revised 05.13.2014 Dawson County Planning & Development 25 Justice Way, Suite 2322, Dawsonville, GA 30534 (706) 344-3500 ext. 42335 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 Gross Food Receipts for the month = Gross Alcohol Receipts for the month (Beer, Wine, Distilled Spirits) = Gross Alcohol Receipts for the month (Beer & Wine Only) = Gross Taxable Receipts for the month (Distilled Spirits Only) = Three Percent Tax due on Gross Distilled Spirits Receipts = Less 3% Discount = (If remitted on or before the 10th day of the succeeding month.) Add 10% penalty = (If remitted on or after the 20th day of the succeeding month.) NET TAX DUE ON DISTILLED SPIRITS: Excise Tax payments on Distilled Spirits are required under Article III of the Dawson County Consolidated Alcohol Ordinance. 1. 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. 2. I understand that if the County Commission 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. 3. 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. 4. 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. 5. 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, mail, or fax to: Dawson County Planning & Development Attn: Alcohol Licensing, 25 Justice Way, Suite 2322, Dawsonville, GA 30534 Fax: (706) 531-2725 ***ALL ALCOHOL LICENSEES MUST COMPLETE THIS FORM, HOWEVER EXCISE TAX IS PAID ONLY ON DISTILLED SPIRITS***