DIRECT SHIPPER STATEMENT Tax Report of Cider and Wine Shipped to Residents Within the State of Oregon Name Month of Year Address City State OLCC License Number (A) CIDER (Barrels) (B) WINE 14% & UNDER (Gallons) (C) WINE OVER 14% (Gallons) $ 2.60 $ 0.67 $ 0.77 1. Taxable Product Shipped to Oregon Resident (Schedule 11) 2. Authorized Deductions (Schedule 12) 3. Total Taxable Distribution (Line 1 Minus Line 2) 4. Rate of Tax $ 5. Amount of Tax (Line 3 x 4) $ $ 6. TOTAL TAX (Total of Columns A, B, & C - Line 5) $ 7. Other Additions (or Deductions) $ 8. Penalty - 10% of Delinquent Tax of Late Payment $ 9. Interest - 1% of Delinquent Tax per Month or Fraction of a Month $ 10. Audit Adjustments - Charges (or Credits) $ 11. TOTAL TAX, PENALTY and OTHER ITEMS DUE $ (Total of Lines 6 through 10) - Enclose Remittance Certification I certify that I am the duly appointed and qualified ______________________________ of the ____________________________________________________________ (Official Position) (Licensee) and that the foregoing statement, with accompanying schedules, is a full, true, and complete report of cider and wine directly shipped to Oregon residents by said permit holder during the month or period above stated. (Phone Number) (Signature) (Printed Name) NOTE : Reports for the preceding calendar month are due on or before the 20th day of each month, if not paid a penalty of 10% and interest at the rate of 1% a month or fraction of a month shall be added and collected. Mail Reports To: OREGON LIQUOR CONTROL COMMISSION PRIVILEGE TAX SECTION PO BOX 22297 MILWAUKIE, OREGON 97269-2297 For O.L.C.C. Accounting Use Only Control Number Over . . . . . . . . . . . . . . . . . . . $ DS1 (Est. 7/07) Short . . . . . . . . . . . . . . . . . . . $ American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS DIRECT SHIPPER STATEMENT All Direct Shipper transactions must be reported on this Statement. Name - Trade Name as it appears on your OLCC license Month - Month report refers to Year - Year report refers to Address - Physical address of Licensed Premise (do not enter mailing address) City & State - City and State of premise physical address OLCC License Number - OLCC license number of current certificate Complete the information for each column as needed. Taxable Product shipped into Oregon (Line 1) -Taxable product total from Schedule 11 Authorized Deductions (Line 2) - Authorized deductions totals from Schedule 12 Total Taxable Distribution (Line 3) - Line 1 Minus Line 2 Rate of Tax (Line 4) - Current Rate of tax Amount of Tax (Line 5) - Line 3 multiplied by Line 4 Total Tax (Line 6) - Total of Columns A, B & C - Line 5 Other Additions (or Deductions) (Line 7) - Adjustments regarding error letters received from OLCC Penalty (Line 8) - Penalty due on late reports or errors Interest (Line 9) - Interest due on late reports or errors Audit Adjustments (Line 10) - Audit adjustments as indicated on your audit report Total Tax, Penalty and Other Items Due (Line 11) - Total of Line 6 to Line 10 - Enclose remittance Certification - Required declaration of accurate and complete statement Official Position - Position Title for legal entity (For example, Owner, President, etc.) Licensee - Trade Name of the company as it appears on your OLCC license Phone Number - Number at which licensee can be reached Signature - Signature of person listed in Official Position Printed Name - Printed name of person listed in Official Position This report must be completed monthly by all Direct Shippers. The report must be postmarked on or before the 20th of the month following the reporting period. When the 20th falls on a Saturday, Sunday, or a legal holiday, the filing must be postmarked by the U. S. Postal Service no later than the next postal business day. When reporting Barrels/Gallons, carry the decimal to two places. Decimals of .005 or larger should be rounded up. Example 12.387 would be reported as 12.39. Decimals of .004 and lower should be dropped. Example 12.384 would be 12.38. DS1 Instructions (07/07) American LegalNet, Inc. www.FormsWorkFlow.com