Form 47-270 STATEMENT OF MONIES PAID for CALENDAR YEAR DATE: MAIL TO: Alcoholic Beverage Control Division, Mississippi State Tax Commission, P.O. Box 540, Madison, Mississippi 39130-0540 In compliance with the provisions of Mississippi Code, Annotated, Section 67-1-49 (1972), we list below the names and addresses of each person, firm or corporation doing business in Mississippi in any manner to whom or which we, the undersigned, paid or agreed to pay any fee, retainer, salary or remuneration during the calendar year , together with other information required under Section 2 of the aforesaid statute: 1. NAME: (Person, firm or corporation) ADDRESS: TYPE OF BUSINESS OR ACTIVITY: TOTAL AMOUNT OF ALL PAYMENTS: $ TYPE OF PAYMENT: IF EXPENSES PAID, SPECIFY AMOUNT: $ ___Fee ___Retainer ___Other (specify): ___Salary ___Commission ___Expenses Purpose: 2. NAME: (Person, firm or corporation) ADDRESS: TYPE OF BUSINESS OR ACTIVITY: TOTAL AMOUNT OF ALL PAYMENTS: $ TYPE OF PAYMENT: IF EXPENSES PAID, SPECIFY AMOUNT: $ ___Fee ___Retainer ___Other (specify): ___Salary ___Commission ___Expenses Purpose: We hereby certify that the above named persons, firms or corporations are the only ones who or which received any fee, retainer, salary, or other remuneration form us during the calendar year . We further certify that we understand thoroughly the provisions of the aforesaid Mississippi Code, Annotated, Section 67-1-49 (1972), and that failure to file a full, complete, and accurate statement of fees, retainers, salaries, and other remuneration’ paid by us to persons, firms, and corporations doing business in the State of Mississippi will constitute s grounds for the Mississippi State Tax Commission to suspend our right to sell to the Commission until such time as said statement shall be filed. (Name of Vendor) (Title) Date: Sworn to and subscribed before me this the day of , 20 . American LegalNet, Inc. www.FormsWorkflow.com