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MALT BEVERAGE AND WINE FOR CONSUMPTION ON THE PREMISES LICENSE REPORTING FORM Pursuant to Morgan County Code of Ordinance § 6-356, Malt Beverage and Wine for Consumption on the Premises License, the Licensee is required to file with Morgan County a sworn statement of the Licensee’s sales during the preceding calendar quarter, including the gross sales of malt beverages and wine separated from the gross sales of food items. Licensee: License Number: Establishment: Phone Number: Address: Calendar Year: Quarter: 1 2 3 4 (circle one) Gross Food Sales Gross Alcohol Sales Total Sales Month 1 Month 3 Total: Total: Total: Month 2 Licensee must attach copies of all receipts showing quarterly food sales indicated above. Additionally, Licensee must attach certified copies of Licensee’s State of Georgia Department of Revenue Sales and Use Tax Reports as filed with the Georgia Department of Revenue for each month during the quarter indicated above. Licensee attaches pages to this form. I hereby swear under penalty of perjury that the information contained in, and attached to this form is true and correct. Subscribed and sworn before me on this Licensee (sign name) (print name) Date Notary Public My Commission Expires: