STATE OF INDIANA ALCOHOL AND TOBACCO COMMISSION 302 West Washington Street IGCS Room E114 Indianapolis, IN 46204 Telephone 317 / 232-2430 Fax 317 / 233-6114 www.IN.gov/atc SUPPLEMENT FOR DIRECT WINE SELLER’S PERMIT APPLICATION The applicant, ___________________________, seeks a Direct Wine Seller’s Permit under Indiana Code 7.1-3-26. The applicant: 1. Is domiciled and has its principal place of business in the United States; 2. is engaged in the manufacture of wine; 3. holds and acts within the scope of authority of an alcoholic beverage license or permit to manufacture wine that is required by Indiana or the state in which the applicant is domiciled and by the Tax and Trade Bureau of the United States Department of the Treasury; 4. qualifies with the Indiana Secretary of State to do business in Indiana; 5. consents to the personal jurisdiction of the Indiana Alcohol & Tobacco Commission and the Indiana courts; 6. The applicant files a surety bond with the commission in accordance with IC 7.1-3-1;  sells not more than five hundred thousand (500,000) gallons of wine per year in Indiana, excluding wine shipped to an out-of-state address;  Kas not distributed wine through a wine wholesaler in Indiana within the one hundred twenty (120) days immediately preceding the applicant's initial application for a direct wine seller's permit or the applicant has operated as a farm winery under IC 7.1-3-12; and . Ls not the parent, subsidiary, or affiliate of another entity manufacturing any alcoholic beverage. I certify that this supplement was completed by myself and that any attachments are true and correct. I UNDERSTAND THAT IT IS A FELONY TO MISREPRESENT OR FALSIFY ANY PORTION OF THIS APPLICATION OR ATTACHED DOCUMENTS. ________________________________________________ Signature of Applicant _________________________ Date (month, day, year) Name of Applicant ______________________________________________________________ Doing Business As (d/b/a): __________________________________________________________ Address (number and street): ______________________________________________________ City, State, and ZIP code: __________________________________________________________ Telephone Number: ______________________________________________________________ State Form 54364 (7-10) American LegalNet, Inc. www.FormsWorkFlow.com