Sales Record, Keg Label, and Keg Purchaser Affirmation KEG LABEL FOR EACH KEG SOLD, COMPLETE THIS FORM. LICENSEE RETAINS THE ORIGINAL. ONE COPY TO PURCHASER. ONE COPY AFFIXED TO KEG IN CLEAR PLASTIC ENVELOPE. UNIQUE IDENTIFICATION NUMBER: NEW YORK STATE KEG REGISTRATION PROGRAM Address of the Licensee selling the Keg (PRINTED): S E L L E R Name of the Person making the Sale (PRINTED): SIGNATURE of the Person making the Sale: Product Brand and Size of Keg (PRINTED): Product Brand Size of Keg Amount of the Licensee's Container/Equipment Deposit: Amount of the State Keg Registration Deposit: $75 to be forfeited to the Seller if the Keg is not returned with the Keg Label affixed and undamaged within 90 days of Sale / Date and Time of Sale: Month : / Day Year Hour Minute AM or PM P U R C H A S E R Name of the PURCHASER of the Keg (PRINTED): Address of the PURCHASER of the Keg (PRINTED): IDENTIFICATION PRESENTED BY THE PURCHASER THE SELLER MUST MAINTAIN A WRITTEN RECORD DOCUMENTING THAT THE KEG PURCHASER PRESENTED PROPER AND VALID IDENTIFICATION. WRITE IN THE BOX BELOW THE IDENTIFICATION CARD NUMBER AND THE EXPIRATION DATE APPEARING ON THE FACE OF AN ACCEPTABLE FORM OF IDENTIFICATION ISSUED BY AN APPROPRIATE GOVERNMENTAL AGENCY. THEN INDICATE THE TYPE OF IDENTIFICATION PRESENTED BY CHECKING ONE BOX IN EACH OF THE TWO COLUMNS WHICH FOLLOW AND SPECIFYING ANY ADDITIONAL FACTS REQUIRED. EXPIRATION DATE IDENTIFICATION NUMBER / Month ↓ CHECK ONE BOX IN EACH OF THE TWO COLUMNS BELOW FORM AUTHORIZED BY THE NEW YORK STATE LIQUOR AUTHORITY IDENTIFICATION WAS ISSUED BY New York State □ Valid Driver's License □ Valid Non-Driver Identification Card ↓ (SPECIFY ADDITIONAL FACTS WHERE REQUIRED) Other State ______________________________ (Specify) □ □ Federal Government □ United States Territory, Commonwealth or Possession (Specify)______________________ □ District of Columbia □ Provincial Government of the Dominion of Canada □ The United States Government □ Valid Passport □ Valid Identification Card issued by the Armed Forces of the United States DISTRIBUTION: The Country of ___________________________ (Specify) DO NOT ACCEPT A FORM OF IDENTIFICATION UNLESS YOU ARE FULLY FAMILIAR WITH ITS CHARACTERISTICS AND HAVE CAREFULLY COMPARED THE PHOTOGRAPH ON THE IDENTIFICATION WITH THE PERSON PRESENTING IT DAMAGING OR UNLAWFULLY REMOVING THIS KEG LABEL IS SUBJECT TO A CRIMINAL FINE OF BETWEEN $250 AND $450. KEG RETURNED / Month : / Day Year Hour Minute AM or PM Keg Purchaser Affirmation Year TYPE OF IDENTIFICATION PRESENTED BY THE PURCHASER ACCEPTABLE FORMS OF IDENTIFICATION Keg Form (10-15-04 / Rev. 02) - / Day T R A N S A C T I O N To use this form as the Keg Label. Fold this form in quarters so that the seller and purchaser information on the upper right corner of the form is visible. Place it in the Clear Plastic Envelope, making sure that the upper right corner of the form is facing out, and affix the envelope to the Keg Name of the Licensee selling the Keg (PRINTED): □ □ By my signature below, I attest under penalty of perjury that I am the purchaser of the keg of beer listed above. I attest under penalty of perjury that my true name is accurately written on this form, and understand that a copy of this form will be attached to the keg I have purchased. I acknowledge that I have reviewed a copy of Laws related to the Underage Purchase and Consumption of Alcohol, which copy sets forth relevant provisions from Alcoholic Beverage Control Law sections 65-a (Procuring Alcoholic Beverages for Persons Under the Age of Twenty-One Years), 65-b (Purchase or Attempt to Purchase an Alcoholic Beverage through Fraudulent Means), and 65-c (Unlawful Possession of an Alcoholic Beverage with the Intent to Consume by Persons Under the Age of Twenty-One Years), and section 260.20 of the Penal Law (Unlawfully Dealing with a Child in the First Degree). I attest under penalty of perjury that I will not allow any of the beer from the keg I have purchased to be consumed in violation of sections 65-a, 65-b, and 65-c of the Alcoholic Beverage Control Law, and section 260.20 of the Penal Law. I affirm that these representations are true under penalty of perjury, and understand that I may be criminally prosecuted for making a false written statement. Signature Identify Branch of the Armed Forces _____________________ (Specify) WHITE COPY – TO BE KEPT BY SELLER WITH KEG SALES RECORDS Date YELLOW COPY – TO BE USED AS THE KEG LABEL PINK COPY- TO BE GIVEN TO THE KEG PURCHASER American LegalNet, Inc. www.FormsWorkflow.com