MALT BEVERAGES / CIDER IMPORTED INTO OREGON TO WHOLESALERS Name: Address City Month Year Invoice Date State OLCC License Number Invoice Number (Barrels) Malt Beverage / Cider Sold To Name Address City State Zipcode Phone Number OLCC License Number SUMMARY TOTALS FOR IN STATE OREGON LICENSEE Name Address City State Zipcode Phone Number OLCC License Number SUMMARY TOTALS FOR IN STATE OREGON LICENSEE Name Address City State Zipcode Phone Number OLCC License Number SUMMARY TOTALS FOR IN STATE OREGON LICENSEE Name Address City State Zipcode Phone Number OLCC License Number SUMMARY TOTALS FOR IN STATE OREGON LICENSEE GRAND TOTAL INSTRUCTIONS - SUBMIT ONE COPY OF THIS REPORT Certified True and Correct Under Penalty of Perjury & COPIES OF INVOICES TO: Signature of Person OREGON LIQUOR CONTROL COMMISSION Completing Form PRIVILEGE TAX SECTION Printed Name PO BOX 22297 Date MILWAUKIE, OREGON 97269-2297 Telephone Number IN ACCORDANCE WITH ORS 471.289 AND OAR 845-010-0170, THIS REPORT IS DUE ON OR BEFORE THE 20TH OF EACH MONTH SHOWING THE BARRELS OF MALT BEVERAGES DELIVERED TO EACH LICENSEE OF THE COMMISSION DURING THE PRECEDING MONTH. A COPY OF EACH INVOICE LISTED MUST BE FURNISHED TO THE OREGON LIQUOR CONTROL COMMISSION. Note : This report is not required if there are no shipments in a given month. CERAMALT/CIDER (REV 11/07) American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR CERTIFICATE OF APPROVAL HOLDERS SHIPPING TO OREGON WHOLESALERS All Malt Beverages and Cider shipped into Oregon, to Oregon wholesalers, by Certificate of Approval licensees must be reported to the Oregon Liquor Control Commission. Name - Your trade name as it appears on your OLCC license. Address, City & State - Premises address as it appears on your OLCC license. Month - Month report refers to. Year - Year report refers to. OLCC License Number - OLCC license number of current certificate. List each Oregon Wholesaler Alphabetically by Company Name. Invoice Date - Invoice Date on the invoice Invoice Number – Invoice Number on the invoice Sold To - Name, Address, City, State, Zip code & Phone # of the company the Product was sent to. OLCC License Number – The OLCC License number of the company you are shipping the product to. Malt Beverage and Cider Barrels – enter total barrels. Summary Total for Oregon Licensee - Summary total for each Oregon wholesaler product shipped to. Grand Total – Total barrels shipped into the State. A copy of Each Invoice listed must be provided with this Report Signature of Person Completing Form - Signature of person certifying accuracy of report Printed Name - Printed name of person certifying accuracy of report Date - Date report completed Telephone Number - Telephone number at which licensee can be reached. Barrelage Factors for Common Container Sizes 1/2 Barrel = .50 1/4 Barrel = .25 12 Gallon Keg = .3871 13.2 Gallon Keg = .4258 12 bottles @ 11 oz. Case = .0333 12 bottles @ 12 oz Case = .0363 12 bottles @ 22 oz Case = .0665 12 bottles @ 25 oz Case = .0756 12 bottles @ 25.4 oz Case = .0768 12 bottles @ 32 oz Case = .0968 12 bottles @ 40 oz Case = .1210 15 bottles @ 12 oz Case = .0454 20 bottles @ 12 oz Case = .0605 24 bottles @ 11.2 oz Case = .0677 24 bottles @ 12 oz Case = .0726 50 Liter Keg = .4261 30 Liter Keg = .2556 8 Liter Keg = .0682 12 bottles @ .750 Liters = .0767 12 bottles @ .375 liters = .0384 When reporting barrels, 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. The total amount of Barrels per invoice can be calculated by: Multiplying the number of containers by factors shown below for that case size. If other size containers are received, the factor can be calculated by Number of bottles in case multiplied by number of ounces in each bottle = total ounces. Divide the total ounces by 3968 to get the factor. Factor multiplied by number of cases = Barrels Converting Liters to Gallons: Liters multiplied by .26417 = Gallons 31 Gallons = 1 Barrel This form should be prepared in duplicate: One copy to OLCC, One copy for your records. This report is not required if there are no shipments into Oregon in a given month. CERAMALT INSTRUCTIONS (Est 11/07) American LegalNet, Inc. www.FormsWorkFlow.com