MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL P.O. BOX 837, JEFFERSON CITY, MO 65102 MO LICENSE NUMBER MONTH YEAR FORM 190 MANUFACTURER OR DOMESTIC WINERY (AS LICENSED WITH MISSOURI) STREET ADDRESS CITY, STATE, ZIP CODE The original of this report must be postmarked to the office of the Division of Alcohol and Tobacco Control, Jefferson City, Mi ssouri, not later than the 15th of each month. Duplicate copy to be retained for your files. Copies of all invoices and credits (with explanation) must be submitted with this form. SECTION A SPIRITUOUS ALCOHOL GALLONS LINE 1 WINE ALCOHOL GALLONS Untaxed Bulk Spirituous and/or Bulk Wine on Hand First of Month Enter as Item 1 on Form MANU Enter as Item 1 on Form MANU 2 Untaxed Bottled Spirituous and/or Bottled Wine on Hand First of Month 3 TOTAL NUMBER OF GALLONS ON HAND FIRST OF MONTH 4 Untaxed Bulk Spirituous and/or Bulk Wine Produced During Month 5 Untaxed Spirituous Bottled and/or Wine Bottled During Month 6 Spirituous and/or Wine Sold During Month (in gallons) Enter as Item 2 on Form MANU Enter as Item 2 on Form MANU SECTION B – ALCOHOL LIQUORS RECEIVED UNTAXED REPORT IN (WINE/SPIRIT) GALLONS LINE 7 INVOICE NUMBER AND DATE PURCHASED FROM NAME AND ADDRESS TOTAL ALCOHOLIC LIQUOR RECEIVED UNTAXED MO 812-1270N (1-07) REMARKS SPIRITUOUS LIQUOR WINES Enter as Item 3 on Form MANU Enter as Item 3 on Form MANU STATE WHETHER IN BOND, DIRECT IMPORT, BULK, OR OTHER REASON FOR BEING UNSTAMPED. PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkflow.com SECTION C – REPORT OF CLAIMS FOR TAX EXEMPTION Manufacturer reports in this section all claims for tax exemption due to out of state sales, unstamped bonded merchandise, breakage, tasting samples, family use, and in-bond shipments. A report of wine shipped on each outstate shipment must accompany report. Supporting data on breakage, tasting samples, etc. must be kept on file in your office for review by our auditors. REPORT IN (WINE/SPIRIT) GALLONS LINE 8 INVOICE NUMBER AND DATE SOLD TO NAME AND ADDRESS TOTAL DEDUCTIONS FOR TAX EXEMPTION SPIRITUOUS LIQUOR WINES Enter as Item 6 on Form MANU Enter as Item 6 on Form MANU INVOICE NUMBER AND DATE TAXED OR UNTAXED EXPLANATION (STATE REASON FOR EXEMPTION) SECTION D – SALES TO WHOLESALE DEALERS WHOLESALER’S MO. LICENSE NO. WHOLESALER’S NAME WINE GALLONS SPIRITS WINES TOTAL SALES TO WHOLESALE DEALERS MO 812-1270N (1-07) PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkflow.com