OUT OF STATE SUPPLIER REPORT OF ALCOHOLIC BEVERAGES SHIPPED TO DELAWARE IMPORTERS TO: DELAWARE DIVISION OF REVENUE BUSINESS AUDIT BUREAU ATTN: William J. Kirby 820 N. FRENCH STREET WILMINGTON, DE 19801 WILLIAM.KIRBY@STATE.DE.US Shipments of alcoholic beverages to Delaware Importers for the month of: Check here if you had no shipments to report during this month. INVOICE NUMBER P.O. NUMBER NAME OF DELAWARE IMPORTER TYPE W,HS.LS C,B TOTAL TOTAL TOTAL GALLONS BARRELS CASES (W,HS,LS,C) (BEER) License No. TYPE WINES HIGH SPIRITS LOW SPIRITS CIDER BEER W= HS = LS = C= B= DATE The information submitted in the foregoing report is certified to be a full, true and correct statement of the out of state supplier named below to the knowledge and belief of the undersigned. Copies of invoices are not required. Report is due by the 15th of the month. NAME OF SUPPLIER DATE NAME OF OFFICER SIGNATURE TELEPHONE NUMBER American LegalNet, Inc. www.FormsWorkFlow.com