For Questions call (614) 644-2411 Office Hours 8:00 to 5:00 Ohio Department of Commerce - Division of Liquor Control 6606 Tussing Road, Reynoldsburg, Ohio 43068-9005 http://www.com.ohio.gov/liqr S PERMIT HOLDER SHIPMENT OF BEER OR WINE REPORTING FORM Pursuant to Ohio Revised Code 4303.232, the holder of an S permit is required to provide annually a report to the Division of Liquor Control the name, address, and quantity of beer or wine purchased by each personal consumer in Ohio from the S permit holder. The submission of this form to the Division of Liquor Control must be done no later than March 1st for the prior January through December 12 month period. Please provide your email address in the designated area below. Beer or wine shipped to Ohio Consumers January 1st through December 31st, (ENTER FILING YEAR) Permit Holder Name: Permit Premises Address City Telephone Number State Email Address S Permit Number: Zip Code * If reporting Cases of wine shipped they should be reported as 750 ML - 12 bottle cases or equivalent cases containing nine liter total volume. If reporting bottles of wine shipped they should be reported in 750 ML bottle equivalents. NAME OF OHIO CONSUMER SHIPPING ADDRESS *Cases Shipped *Bottles Shipped I certify the above information to be an accurate record of shipments made to Ohio personal consumers. ____________________________________ ___________________________ _________________ Print Name Title Date DLC4231 EOE/ADA Service Provider For TTY Users Dial ORS 1-800-750-0750 Rev. 01/2016 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 Permit Holder Name: S Permit Number: * If reporting Cases of wine shipped they should be reported as 750 ML - 12 bottle cases or equivalent cases containing nine liter total volume. If reporting bottles of wine shipped they should be reported in 750 ML bottle equivalents. NAME OF OHIO CONSUMER SHIPPING ADDRESS *Cases Shipped *Bottles Shipped DLC4231 American LegalNet, Inc. www.FormsWorkFlow.com