PLEASE COMPLETE PAGE 1 AND 2 (TYPE OR PRINT PLAINLY) Type of Applicant: FOR DIVISION USE ONLYTaxing DistrictRemarks:Reviewer Action:Permit NumberReceipt # DLC 1615EOE/ADA SERVICE PROVIDERPage 1FOR TTY USERS DIAL ORS 1-800-750-0750 Rev. 4/2019 PLEASE SEE PAGE 2 FOR "IMPORTANT ADDITIONAL INFORMATION" A-2 permit holder Please indicate your permit number Please indicate your permit number S-5 license holder (Out of State Supplier), issued by the State of Ohio.Business Address: City: Zip Code:State:Name of Applicant: uestions on Status of ation - ffeusaeneral Questions - 614.644.2411 B-2A PERMIT $100 (Non-Refundable) PROCESSING FEE - Made payable to Division of Liquor ControlCertificate (S-5), OR have an Out of State Supplier application pending with the Division's Beer and Wine Section.247 4303.071(A)States in part, permit B-2a may be issued to a person that is the brand owner or United States importer of wine, is the designated agent of a brand owner or importer for all wine sold in this state for that owner or importer, or manufacturers wine if such manufacturer is entitled to a federal wine tax credit under 27 C.R.R.24.278 and produces less than two hundred fifty thousand gallons of wine per year. If the person resides outside this state, the person shall comply with the requirements governing the issuance of licenses or permits that authorize the sale of intoxicating liquor by the appropriate authority of the state in which the person resides or by thealcohol and tobacco tax and trade bureau in the United States department of the treasury. The holder of a B-2apermit may sell wine to a retail permit holder, but a B-2a permit holder that is a wine manufacturer may sell to a retail permit holder only wine that the B-2a permit holder has manufactured. American LegalNet, Inc. www.FormsWorkFlow.com THE FOLLOWING MUST BE COMPLETED BY THE APPLICANT(S): 1a. Is the manufacturer of the wine entitled to a federal wine tax credit under 27 C.F.R. 24.278?1b. Does the manufacturer of the wine produce less than 250,000 gallons of wine per year?2. Please submit a copy of your Federal Basic Permit issued by the U.S. Department ofTreasury, Alcohol and Tobacco Tax and Trade Bureau (TTB).DELIBERATE MISREPRESENTATION OF ANY OF THE INFORMATION ON THE APPLICATION CANRESULT IN THE DIVISION'S REFUSING TO APPROVE THIS APPLICATION.(To be completed by Notary Public)Sworn to before me and subscribed in my presence this day of , 20 (Notary Public) (Notary Expiration)Page 21. Does the applicant manufacture wine?If YES, please answer questions 1a. and 2a. IMPORTANT ADDITIONAL INFORMATION All B-2a permits expire October 1st of each year. Any B-2a permit issued April through September will receive a 50% refund ofthe class fee. An applicant for a B-2a permit is also required to register as an Out-of-State Supplier and pay a $100.00 initialApplication Fee. This fee must be separate from the $25.00 B-2A Permit Fee . The yearly renewal of the Out-of-StateSupplier's license with a B-2a is $76.00. In addition to registering as an Out-of-State Supplier, a B-2a permit holder mustregister each product sold in Ohio and pay a $50.00 product registration fee for each product. Ohio has exclusive sales territo-ries for wine products sold to retail permit holders through an Ohio wholesale distributor. If you also wish to sell your productsthrough an Ohio wholesale distributor, it will be necessary for you to complete a territory designation form for each brand youregister.Please visit the Division's web site at www.com.ohio.gov/liqr and under "Featured" - "Applications & Forms" - "Beer & WineSection..." you can download the necessary forms needed to register as an Out-of-State Supplier and to register your products.If you have any questions, please contact the Beer and Wine Section at 614-644-2411. DLC 1615 NO YES NO YES NO YESCounty, ss being first duly sworn, according to law, depose and say that the statements(Please Print)and answers made in the foregoing application are true.(Signature of Individual, Partner, Officer, Managing Member, or 5% or more Stockholder or Member) (Title)(Date)(Residence Address)(City)(State)(Zip Code) (Area Code & Telephone Number) I, State of Ohio, American LegalNet, Inc. www.FormsWorkFlow.com