North Carolina Alcoholic Beverage Control Commission Wine Shipper - Quarterly Shipment Report This form must be completed quarterly and received by the Commission by the 15th day of the month immediately following each quarter. Quarters - January 1 - March 31, April 1 - June 30, July 1 - September 30, October 1 - December 31 Please print or type. DATE OF SHIPMENT BRAND NAME TYPE Price per Bottle Quantity in Liters Page of AMT. EXCISE AMT. SALES TAX PAID TAX PAID Permittee Name: Permittee Address: Permittee Phone Number: Email Address: Permit Number: OATH OF APPLICANT I certify as required by NCGS 18B-902(a) and (c) that this document is true, correct and complete to the best of my knowledge. Not more than 2 cases (18 liters) have been shipped/sold to any one individual within one month. Total number of cases shipped this calendar year to date (9 liters per case). Printed Name and Position of Authorized Official: Signature of Authorized Official: Date NC Wine Shipper Brand Listing - 10/03 American LegalNet, Inc. www.FormsWorkflow.com