ATT-62 (REV 8/11) GEORGIA DEPARTMENT OF REVENUE PROCESSING CENTER P.O. Box 105458 ATLANTA, GA 30374-5458 GEORGIA FARM WINERY MONTHLY REPORT NAME OF WINERY ADDRESS RETURN TO BE FILED ON OR BEFORE THE 15TH DAY OF THE FOLLOWING MONTH FOR WHICH THE REPORT IS FILED FOR CALENDAR MONTH/YEAR STATE LICENSE # CITY ZIP CODE REPORT IN LITERS FOREIGN WINES SUMMARY OF WINE TRANSACTIONS DURING CALENDAR MONTH 14% OR LESS DOMESTIC WINES OVER 14% 14% OR LESS BLEND - GA: OVER 14% % / F: %14 OR LESS % OVER 14% 1. Removed from Winery (Total lines 8 and 9, Schedule A) 2. Sales to Georgia Wholesalers (Total Schedule C) 3. Sales out-of-State (Total Schedule D) 4. Sales to Licensed Retail Dealers (Total Schedule E) 5. Sales to Consumers and Withdrawals for Tastings (Total Schedule H) 6. Total taxable this month (Line 4 and Line 5) 7. Wine excise tax rate per liter by class $ .40 $ .67 $ .11 $ .27 $ $ 8. Gross tax due each class of wine (Line 6 x applicable tax rate as shown on Line 7) $ $ $ $ $ $ 9. Gross tax due (Total of all columns in line 8) $ AFFIDAVIT I certify, under the penalties for filing false returns, that I have personal knowledge and understanding of statements made in this return and that the figures presented herein, including accompanying schedules, are true, correct and complete to the best of my knowledge and belief, and are filed in accordance with law. SIGNATURE OF OWNER, PARTNER OR OFFICER TITLE DATE American LegalNet, Inc. www.FormsWorkFlow.com