B-C-715 Web 2-11 Beer Shipping Report Nonresident Vendor or Resident Brewery North Carolina Department of Revenue DOR Use Only (MM-DD-YY) Return for Month Ended FEIN or SSN Legal Name (First 35 Characters) (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS) Trade Name NCDOR ID/Account Number Mailing Address City State Zip Code ABC Permit Number Name of Contact Person State of Domicile Fill in circle if applicable: Phone Number Fax Number Amended Return No Transactions Number of Gallons of Beer Sold In North Carolina During Month Invoice Date Invoice Number Names and Addresses of Wholesalers, Importers, and Purchasers (In Gallons) Beer Gallons Sold (From Page 2) Total Gallons Sold (Add the total amount of gallons reported for the month and enter the sum.) (continued on Page 2) , , Signature: I certify that, to the best of my knowledge, this return is accurate and complete. Title: Date: For your convenience, electronic payment methods are available through our website at www.dornc.com. This report must be filed monthly by each nonresident vendor or resident brewery that sells malt beverages in North Carolina, including any sample products. The report is due on or before the 15th day of the month following the month in which the beverages are sold and must list the total gallons of beer by invoice. Copies of invoices covering shipments made into North Carolina must be maintained for three years for audit purposes. A report is due even if there are no transactions for the month. North Carolina Department of Revenue, PO Box 25000, Raleigh, North Carolina 27640-0110 American LegalNet, Inc. www.FormsWorkFlow.com Page 2, B-C-715, Web, 2-11 Legal Name NCDOR ID Number of Gallons of Beer Sold In North Carolina During Month (continued from Page 1) Invoice Date Invoice Number Names and Addresses of Wholesalers, Importers, and Purchasers (In Gallons) Beer Gallons Sold (Add the total amount of gallons reported on this page and enter the sum here and on Page 1) , , American LegalNet, Inc. www.FormsWorkFlow.com