ATT-148 (Rev. 7/14) Due by the 15th of each month following month in which shipments were made. Georgia Department of Revenue Alcohol and Tobacco Division 1800 Century Center Suite 4235 Atlanta, GA 30345 Telephone: (404) 417-4900 E-mail: ATDIV@dor.ga.gov CARRIERS MONTHLY REPORT OF ALCOHOLIC BEVERAGE SHIPMENTS DELIVERED IN THE STATE OF GEORGIA Affidavit for _______________________ FEIN NAME OF CARRIER STREET ADDRESS CITY STATE ZIP CODE IMPORTANT INSTRUCTIONS THIS AFFIDAVIT MUST BE FILED WITH THE GEORGIA DEPARTMENT OF REVENUE ON OR BEFORE THE 15TH OF EACH CALENDAR MONTH, COVERING ALL ALCOHOLIC BEVERAGE SHIPMENTS DELIVERED IN THE STATE OF GEORGIA DURING THE PRECEDING CALENDAR MONTH. THIS AFFIDAVIT MUST BE ACCOMPANIED BY COPIES OF ALL BILLS OF LADING FOR THESE SHIPMENTS. AFFIDAVIT BEFORE ME, AN OFFICER AUTHORIZED BY LAW TO ADMINISTER OATHS, PERSONALLY APPEARED __________________________________________________________ AN AUTHORIZED AGENT OF THE ABOVE NAMED BUSINESS, WHO FIRST BEING DULY SWORN DEPOSES AND SAYS THAT THE ATTACHED COPIES OF BILLS OF LADING ARE TRUE AND CORRECT COPIES OF ALL BILLS OF LADING COVERING ALL DELIVERIES OF ALCOHOLIC BEVERAGES IN THE STATE OF GEORGIA MADE DURING THE PRECEDING MONTH, AND ARE SUBMITTED IN ACCORDANCE WITH GEORGIA ALCOHOLIC BEVERAGE CODE. SUBSCRIBED AND SWORN TO BEFORE ME THIS ________ DAY OF _______________, _______ SIGNED ________________________________ AUTHORIZED AGENT ___________________________________________ NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com