ALCOHOLIC BEVERAGE CONTROL Form 47-270-11-1-1-000 (Rev. 11/13) STATEMENT OF MONIES PAID FOR CALENDAR YEAR ___________ Date:________________________________ Mail to: Alcoholic Beverage Control, 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 to which we, the undersigned, paid or agreed to pay any fee, retainer, salary, or remuneration during the calendar year _______, together with other information required by the statute. 1. NAME: ________________________________________________________________________ (Person, firm, or corporation) ADDRESS: _____________________________________________________________________ TYPE OF BUSINESS OR ACTIVITY: ______________________________________________ TOTAL AMOUNT OF ALL PAYMENTS: $ _________ IF EXPENSES PAID, SPECIFY AMOUNT: $ _________ TYPE OF PAYMENT: __ Fee __Retainer __ Salary __ Commission __ Expenses __ Other (specify) __________________________________________ Purpose: ________________________________________________________________________ ________________________________________________________________________ 2. NAME: ________________________________________________________________________ (Person, firm, or corporation) ADDRESS: _____________________________________________________________________ TYPE OF BUSINESS OR ACTIVITY: ______________________________________________ TOTAL AMOUNT OF ALL PAYMENTS: $ _________ IF EXPENSES PAID, SPECIFY AMOUNT: $ _________ TYPE OF PAYMENT: __ Fee __Retainer __ Salary __ Commission __ Expenses __ Other (specify) __________________________________________ 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 from 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 remunerations paid by us to persons, firms, and corporations doing business in the State of Mississippi will constitute grounds for the Mississippi Department of Revenue to suspend our right to sell to the Department until such time as said statement shall be filed. Finally, the person signing this Application certifies under oath that all the information contained in this document is true and correct and he or she has the authority to sign this document as the manufacturer or on behalf of the manufacturer and acknowledges that this Application is being signed under the penalty of perjury pursuant to Mississippi Code Annotated Section 27-3-83(5). By:___________________________________________________________________________________ Name of Officer Title Date American LegalNet, Inc. www.FormsWorkFlow.com P. O. Box 540 Madison, MS 39130 www.dor.ms.gov Phone: 601.856-1301 FAX: 601.856-1390