OMB No. 1513-0005 DEPARTMENT OF THE TREASURY ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB) BREWER'S NOTICE Brewery's Section 1. This is notice serial number 2. The notice date is 3. Our brewery's name is 4. Our trade name is 5. Our business address is (Number and Street) 6. Our brewery location is (City) (County) (State) (Zip Code) (Number and Street) 7. Our main contact person is (Name) (City) (County) (State) TTB can reach me at ( (Zip Code) (Phone Number) Brewery Description 8. Our phone number at the brewery is 9. Our E-mail Address is 10. Our brewery 11. We are a: (check one only) Sole Proprietorship Brewery Brewpub items 9 and 20 ) Pilot Brewing Plant Partnership Corporation Limited Liability Company Limited Partnership 12 . Our employer identification number is: (for example: 12-3456789) 12b. Title to premises and equipment (list names and addresses of owner of land or buildings, or if any other mortgage or encumbrance on the land or buildings of the brewery). 14. We are filing this notice to: give TTB our original notice that we intend to engage in the business of producing beer. amend our previously approved original notice (Registry No. BR ) for the following reason(s): add or delete (circle one) a trade or operating name (attach registration, if your state requires, of new trade or operating name) . List new show a change in brewery premises (attach description of change) . make changes in officers, directors, members, stock, or interest distribution (attach description of change; you must file personnel questionnaires for new personnel and any new person owning 10% or more of total stock) . discontinuance of business as of: (date) other 15. A. We are or are not members of a controlled group of breweries. (List all breweries with shared ownership on a separate sheet of of paper.) B. If you are a member, will the controlled group of breweries produce more than 60,000 but less than 2,000,000 barrels of beer per year? (If so, describe how the reduced rate of tax will be apportioned among brewery members in the controlled group.) . 16. The Internal Revenue Code (IRC) provides that if you produce not more than 2,000,000 barrels per year, you are entitled to a reduced rate of tax on your first 60,000 barrels. What is your estimated production in barrels per year? (check one) More than 2,000,000 barrels per year. We are not entitled to the reduced rate. More than 60,000 barrels per year, but not more than 2,000,000 barrels per year. We are entitled to the reduced tax rate on our first 60,000 barrels removed for consumption or sale. Not more than 60,000 barrels per year. We are entitled to the reduced tax rate on all beer removed for consumption or sale. TTB F 5130.10 (11/2016) Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Signing Authority For Corporate Officials - or am not required to furnish a bond under 27 CFR 25.91. I am not required to furnish a bond only if all of the following are true: I will 17. I am withdraw beer for deferred payment of tax under 27 CFR 25.164, I was liable for not more than $50,000 in beer taxes in the preceding calendar year, and I reasonably expect to be liable for not more than $50,000 in such taxes during the current calendar year. 18. We held our board meeting with (check one) Directors Trustees Managers Governors Date of Meeting We authorize the following corporate officials, employees, or incumbents of the listed offices to execute all documents and to do all acts for us in dealing with the Alcohol and Tobacco Tax and Trade Bureau. (You must impress your corporate seal. If you do not have one, two witnesses must sign.) By the authority of our board, I certify that this authorization is true and complete. Title: Title: Title: Witness: Title: Title: Title: Witness: Brewpub Applicant Information (If you are a brewpub, you must complete this section.) 19. We are a brewpub. Our entire business location is the brewery premises. We understand that by initialing these boxes, we acknowledge that: a. We must separate the brewery operations (non-public area) from the public area of the brewery premises by an adequate partition. Access to the brewery operations must be restricted to authorized visitors and employees only. The serving tanks as noted on our attached diagram are our tax-determined beer tanks. These tanks have a working capacity of approximately barrels/kegs and are accurately calibrated with appropriate measuring devices. We must transfer beer ready for consumption or sale from our fermenters into an empty tax-detemination tank for measurement by the approved measuring device. We will make prompt and accurate records of these transactions to determine tax due. We plan to sell retail liquors other than beer. Attachment Section 21. You must make attachments to complete an original notice. You may also need additional information for an amended notice. Check all the blocks here for your attachments for this notice. For original Brewer's Notices, you must attach all documents for your type of business organization. For amended Brewer's Notices, some forms are mandatory, while others may be optional. Personnel Questionnaires (for all owners/officers/directors/partners/ Articles of Incorporation/Organization (Corporations/LLCs) members/stockholders of over 10%) Trade Name Registrations (if required by state) By-Laws (Corporations/LLCs) Certificate to Transact Business in a Foreign State (if applicable) Power of Attorney (TTB F 5000.8, or Corporate Resolution) Diagram (or Plat/Plan) with dimensions of the brewery Legal description of the Brewery Supplemental Information on Water Quality Considerations (TTB F 5000.30) Partnership Agreement Environmental Information (TTB F 5000.29) Diagram for Brewpub as required Statement Describing the Security at the Brewery Corporate Seal: b. c. 20. All statements and documents are part of this notice. Under penalties of perjury, I declare that I have examined this notice and all attachments and to the best of my knowledge and belief they are true, correct, and complete. 22. Signature of Authorized Person Date 23. Printed or Typed Name and Title Mail this completed package with all attachments to: Director, National Revenue Center, 550 Main St, Ste 8002, Cincinnati, OH 45202-5215 TTB Section - For TTB Use Only This Notice is: Approved Director, National Revenue Center Not Approved Registry Number: BREffective Date: Approval Date: TTB F 5130.10 (11/2016) Page 2 of 5 American LegalNet, Inc. www.F