MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL PO BOX 837 JEFFERSON CITY, MO 65102-0837 WINE DIRECT SHIPPER ANNUAL REPORT AND TAX COMPUTATION CALENDAR YEAR ENDING SUBMIT IN DUPLICATE Prepare tax computation in triplicate, retain one copy for your file, submit TWO COPIES together with certified check, company check, or money order, payable to Director of Revenue for the total amount due, and Sales to Missouri Residents by Wine Direct Shipper form. To avoid penalties, this report must be postmarked to the Division of Alcohol and Tobacco Control, Jefferson City, Missouri, not later than January 31st annually. DIRECT WINE SHIPPER NAME (AS LICENSED WITH MISSOURI) MISSOURI LICENSE NO. ADDRESS STATE CITY ZIP TOTAL TAXABLE SALES TO MISSOURI RESIDENTS ANNUALLY Show Below Totals Of Taxable Sales Which Have Been Detailed On Sales To Missouri Residents By Wine Direct Shipper Form. Item 1 gallons wine (@ $.42 per wine gallon) $ 0.00 Item 2 (If assessed by Division of Alcohol and Tobacco Control) Penalty & Interest $ Item 3 Total tax due on merchandise sold to Missouri residents during calendar year, enter totals of Item 1 and Item 2, if applicable $ 0.00 AFFIDAVIT I am personally familiar with the statements made in this report and swear (or affirm) that the above report, together with attached Sales to Missouri Residents by Wine Direct Shipper, constitutes a true and complete record of our sales to Missouri residents for the calendar year aforesaid, and that all such sales have been made in accordance with the Missouri Missouri Liquor Laws and Regulations. SIGNATURE/TITLE American LegalNet, Inc. www.FormsWorkFlow.com