QUARTERLY BEER SALES REPORT, A1 PERMIT HOLDERS ONLY Ohio Department of Commerce Division of Liquor Control Beer and Wine Section 6606 Tussing Rd., P.O. ox 4005 Reynoldsburg, OH 43068-9005 Tel. No. 614-644-2474 Pursuant to Liquor Control Commission Rule 4301:1-1-67, A1 permit holder sales reports must be filed with the Beer & Wine Section no later than the 15th day of APRIL, JULY, OCTOBER, and JANUARY reflecting sales during the immediate previous three months. FILL IN THE BLOCKS & SPACES BELOW Corporate Name: DBA: Ohio Permit # Phone Number Address: City: State: Zip Code: * Compute Case Sales at 24/12 oz. Equivalent * Compute Keg Sales at 15.5 gal. Equivalent Reporting Period & Due Date Sales to Retail Consumers Sales to Permit Holders Total Sales Jan-Mar (APRIL 15 TH ) Cases Kegs Cases Kegs . . Cases Kegs . . Apr-Jun (JULY 15 TH ) Cases Kegs Cases Kegs . . Cases Kegs . . Jul-Sept (OCTOBER 15 TH ) Cases Kegs Cases Kegs . . Cases Kegs . . Oct-Dec (JANUARY 15 TH ) Cases Kegs Cases Kegs . . Cases Kegs . . I declare under penalties of perjury that this report has been examined by me and to the best of my knowledge and belief is a true, correct, and complete sales report for the period designated. Print Name Title Signature DLC 1540 (Rev. 6-03) Date of Signature EEO/ADA SERVICE PROVIDER American LegalNet, Inc. www.FormsWorkflow.com