Business name:

Business address:

Reporting period (July 1 - December 31,):

1. 1. Refund value of filled containers sold to dealers:
2. 2. Refunds paid to dealers:
3. 3. Refunds paid to redemption centers:
4. 4. Refunds paid to third-party collecting agents:
5. 5. Deposit fund value (line 1 minus lines 2,3, and 4)
6. 6. Handling charges paid to dealers:
7. 7. Handling charges paid to redemption centers:
8. 8. Handling charges paid to third-party collecting agents: