NEVADA DEPARTMENT OF TAXATION 1550 COLLEGE PARKWAY, STE. 115 CARSON CITY, NEVADA 89706 TID: - (10 digit Taxpayer ID# and 3 digit location #) For the month of _ LIQUOR IMPORTER/WHOLESALER MONTHLY REPORT OF EXPORTS ___ Firm Name: Street: City: State: Zip Code: Excise tax credit (Line 3 on LIQ-1) for alcoholic beverages exported from the State of Nevada or manufactured in the State of Nevada (NRS 369.370) A copy of this report must be filed for each State that liquor is exported to. State Exported to Manufacturer purchased from DATE NAME AND ADDRESS WHERE SHIPMENT IS MADE MALT BEVERAGES CITY KEG GALLONS BOTTLE OR CAN GALLONS ALCOHOLIC BEVERAGES GALLONS .5% to 14% GALLONS 14.1% to 22% GALLONS 22.1% to 80% GALLON TOTALS: LESS .25% FORMERLY DISCOUNTED: TOTAL, ENTER ON LINE 3 OF TAX RETURN: The information above is true and correct to the best of my knowledge and belief. Signed Title Date American LegalNet, Inc. www.FormsWorkFlow.com LIQ-3 2/3/11 SUPPLEMENTAL PAGE TO LIQ-1