State of New Hampshire Liquor Commission Direct Shipping Monthly Report Mailing Address: Division of Enforcement Direct Shipping PO Box 1795 Concord NH 03302-1795 Name of Shipper: Physical Address: Division of Enforcement Direct Shipping 57 Regional Drive Suite #8 Concord NH 03301 Contact Info: Tel: (603) 271-8543 Fax: (603) 271-8424 directshippers@liquor.state.nh.us Address: Permit # For the Month of This report must be filed once per month for any month in which a shipment was made so as to arrive at the New Hampshire Liquor Commission on or before the 15th of the following month. Attach to this report a check in the amount of the "Total Amount Due" payable to the New Hampshire Liquor Commission and copies of all invoices shipped into NH. Total # of invoices shipped into NH: Retail Price including shipped costs Less shipped costs Retail Price Beer - = Liquor - = Wine - = Total - = X 0.08 Total Fee at 8% *** NH Liquor Commission issued debit/credit memos Total Amount Due The undersigned hereby swears and affirms that all statements made herein are true and correct to the best of my knowledge and belief and understand that this statement is made subject to the penalties of unsworn falsification described in RSA 641:3. Compliance Company Info: Name: Owner or Officer Address: Contact: *** ( Attach the white copy of the debit/credit memos ) D-006 (Rev 3/8/11) American LegalNet, Inc. www.FormsWorkFlow.com