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Fore preparing this report. For Month oF ACCoUnt nUMBEr Year Page of Pages BUSInESS ADDrESS (street, city, state and zip code) nAME PURCHASED FROM CITY CODE NO. (BOE use only) A B C INVOICE WINE GALLONS DATE RECEIVED REFERENCE NO. DAtE no. AMoUnt 100 ProoF AnD UnDEr oVEr 100 ProoF D E F G H I J totals from previous page 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 TOTALS The original of this report must be mailed to the State Board of Equalization.

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