363 FORM MARYLAND COMMON CARRIER DIRECT WINE SHIPMENT REPORT Federal Employer ID Number (FEIN) 2015 - Common Carrier's Corporate Name and Trading As (T/A) Name Street Address City Email Address State Zip Code Common Carrier Permit Number For Calendar Quarter CC- January � March April � June July � September October - December DELIVERY OF DIRECT WINE SHIPMENTS TO CONSUMERS IN MARYLAND TOTAL NUMBER OF CASES OR BOTTLES OF WINE SHIPPED IN LITERS TO CONSUMERS DURING REPORT QUARTER 1. 2. 3. 4. Size: # of Cases: 4L _______ 3L _______ _______ 1.5L _______ _______ 750ml _______ _______ 375ml _______ _______ 187ml 100ml ________ ________ _______ ________ ________ ________ _______ ________ ________ ________ # of Bottles: _______ Total Liters Shipped by Case or Bottle: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. _______________ I do solemnly declare and affirm under the penalties of perjury that the contents of the foregoing document are true and correct to the best of my knowledge, information and belief. Print name ______________________________________________________________________ Title: Owner, Partner or Officer _____________________________________________________ Signature ______________________________________________________________________ Date ___________________________________________________________________________ COM/RAD-363 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 363 FORM MARYLAND COMMON CARRIER DIRECT WINE SHIPMENT REPORT 2015 Federal Employer ID Number (FEIN) Common Carrier's Name - A Name & Address of Direct Wine Shipper B Date of Shipment C Name & Address of Consumer Shipped to D Date of Delivery to Consumer E Total Liters Shipped 1 2 3 4 5 6 7 8 9 10 In lieu of using this form to report each sale, a hard-copy report with the same information may be submitted. COM/RAD-363 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 363 FORM MARYLAND COMMON CARRIER DIRECT WINE SHIPMENT REPORT 2015 This report must be signed by the owner, partner, or officer of the corporation. If this is a corporation, an officer (President, Vice President, Secretary or Treasurer) must sign. Mail report to: Comptroller of Maryland Revenue Administration Division Returns Processing P.O. Box 2999 Annapolis, Maryland 21404 For more information Telephone: 410-260-7127 or 1-800-638-2937 Fax: 410-974-7924 http://compnet.comp.state.md.us/ http://www.marylandtaxes.com This report shall be properly filed and physically received by the Revenue Administration Division no later than the 21st day of the quarter following the quarter in which wine was shipped to consumers in Maryland. Tax Period January � March April � June July � September October � December Due Date April 21st July 21st October 21st January 21st Page 1 - Delivery of Direct Wine Shipments to Consumers in Maryland Line 1 If a size is not listed on the form, state the size in the blank box and indicate number of cases and bottles shipped Number of cases of wine shipped to consumers for each size Number of bottles of wine shipped to consumers for each size Total amount of all liters of wine shipped by case or bottle (Milliliters must be converted to liters, e.g., 750ml = 0.75 liters) 2 3 4 Page 2 - Each Wine Shipment to Consumers Column A B C D E Line 1-10 1-10 1-10 1-10 1-10 Direct Wine Shipper's name and address Date of shipment of wine to consumer Name and address of consumer shipped to on shipping label Date of delivery of wine to consumer Total liters of wine shipped to address of consumer COM/RAD-363 American LegalNet, Inc. www.FormsWorkFlow.com Page 3