DIRECT SHIPMENT OF ALCOHOLIC BEVERAGES TO OHIO RESIDENTS OHIO EXCISE AND USE TAX FILING A resident of the state of Ohio may import beer, wine or mixed beverages into the state, provided that: (1) (2) (3) (4) (5) (6) (7) (8) Ohio Department of Commerce Division of Liquor Control Beer & Wine Section 6606 Tussing Road, P.O. Box 4005 Reynoldsburg, Ohio 43068-9005 614-644-2411 DIVISION USE ONLY The Ohio resident is an individual who is twenty-one years of age or older. Received __________________________ The alcoholic beverage is for the Ohio resident’s personal use and not for resale. Date All taxes due to the state of Ohio are paid prior to the importation. Sent to The laws of the United States allow the shipment of the alcoholic beverage into the Taxation ___________________________ United States. Date The alcoholic beverage is not registered for sale in Ohio. If the alcoholic beverage is shipped into Ohio, the shipment may only be received by __________________________________ the individual purchaser named on the sales or shipping order. Signature In no event shall the amount of alcoholic beverages brought into Ohio exceed fifteen gallons per family household in any three month period. Only out of state wineries with “S” permits issued by the Ohio Division of Liquor Control may ship wine directly to an Ohio resident. This form is not required when wine is shipped from “S” permit holders. NAME OF OHIO RESIDENT NAME _________________________________________________________________________________________________________ Street Address __________________________________________________________________________________________________ City___________________________ State OHIO Zip _______________ Phone ________________________ NAME OF COMPANY FROM WHOM BEER, WINE OR MIXED BEVERAGES ARE PURCHASED NAME _________________________________________________________________________________________________________ Street Address __________________________________________________________________________________________________ City___________________________ State ___________________ OHIO EXCISE AND USE TAX SECTION Effective January 1, 1993, Ohio EXCISE T AX on beer, wine and mixed beverages is: Type of Alcohol Wine (containing 4% - 14% Apv) Wine (containing more than 14% - 21% Apv) Sparkling/carbonated Wine & Champagne Vermouth Per Case of 12-750 ml bottles $0.76 $2.38 $3.57 $2.62 Zip _______________ Phone ________________________ For questions regarding taxes, call 614-466-7026 Type of Alcohol Per Case Beer (per case of 24 - 12 oz. cans/bottles) Mixed Beverages (per case of 12-750 ml bottles) $0.40 $2.85 SALES/USE TAX is calculated on the purchase price x the applicable county (where you reside) sales/use tax rate: (Example: $250.00 x 7% - $17.50) Type of Alcoholic Beverage (beer/wine/ sparkling vermouth) Brand Product Type Alcohol Content # Cases (% APV wine only) Purchase Price TOTAL Amount of Sales Tax Due $ TOTAL AMOUNT TO BE REMITTED (SALES TAX DUE + EXCISE TAX DUE) Amount of Excise Tax Due $ $ MAKE CHECK OR MONEY ORDER PAYABLE TO: TREASURER OF STATE - Mail check and form to Ohio Division of Liquor Control at the above address SWORN STATEMENT: I declare under penalties of perjury that I am 21 years of age or older, that this filing to the best of my knowledge and belief is true, correct and complete, and that the tax submitted to the State of Ohio is accurate for the above purchases. _______________________________________________________________ Signature of Resident DLC 1516 (Rev. 4-08) _____________________________________________ Date An Equal Opportunity Employer and Service Provider TTY Users Dial ORS 1-800-750-0750 American LegalNet, Inc. www.FormsWorkflow.com