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Form 10 UNION COUNTY, GEORGIA ALCOHOL LICENSING DEPARTMENT By the Package Alcohol Sales Report (Reports are due January 30 and July 30 of each year) Reporting Period: January – June 20__ July – December 20__ BUSINESS NAME: County License # Address: State License # A. Gross Alcohol Sales for reporting period $ B. Gross Fuel Sales (if applicable) for reporting period + $ C. Gross Sales of items other than Alcohol & Fuel for reporting period + $ D. Gross Sales for reporting period = $ 1. For a retail business without fuel sales, percentage of non-alcohol gross sales C/D = % 2. For a retail business with fuel sales (if applicable), percentage of gross sales from sale of items other than alcohol, including only 50% of B. (1/2 of B+C)/D = % Alcohol Ordinance: 10-76 All licensed establishments shall submit to the county at least semi-annually, on or before January 30 and July 30 of each year, or as at such other times as requested, summaries of financial records showing compliance with the required percentage sales requirements, together with copies of back-up documentation, or the electronic equivalent if the county or Alcohol Board agrees. 10-78 ...Malt beverages and wine may be sold by the package in grocery stores and convenience stores which derive at least sixty percent (60%) of their gross receipts semi-annually from the sale of items other than malt beverages, wine, and fifty-percent (50 of gross fuel sales. 10-78 An establishment issued a license under this Ordinance shall be under a responsibility to demonstrate and provide regular proof that the business location for which the license is issued derives at least sixty percent (60%) of total gross sales from the sale of items other than malt beverages, wine, and fifty-percent (50%) of gross fuel sales. I hereby certify that the statements made herein and in any supporting schedules are true, correct, and complete to the best of my knowledge. Printed Name Signature of Preparer Date Phone # Email Address