WINE IMPORTED INTO OREGON TO WHOLESALERS Name: City Address Month Invoice Date Year Invoice Number State OLCC License Number (Gallons) Wine 14% and Under Sold To (Gallons) Wine Over 14% 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 TO: Certified True and Correct Under Penalty of Perjury 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 , CHAPTER 845-10-315, MANUFACTURER'S CERTIFICATE OF APPROVAL, THIS REPORT IS DUE ON OR BEFORE THE 20TH OF EACH MONTH SHOWING THE GALLONS OF WINE DELIVERED TO EACH LICENSEE OF THE COMMISSION DURING THE PRECEDING MONTH. A COPY OF EACH INVOICE LISTED MUST BE FURNISHED TOTHE OREGON LIQUOR CONTROL COMMISSION. Note: This report is not required if there are no shipments in a given month. CERA WINE IMPORTED (REV 8/07) American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR CERTIFICATE OF APPROVAL HOLDERS SHIPPING TO OREGON WHOLESALERS All Wine 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. Wine 14% and under Gallons - enter total wine gallons 14% and under (14.0 % and under) Wine over 14% Gallons - enter total wine gallons over 14% (14.01 % and over) Summary Total for Oregon Licensee - Summary total for each Oregon wholesaler product shipped to. Grand Total - Total gallons 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. GALLON CONVERSION INFORMATION When reporting gallons, carry the decimal to two places Common Gallon Factors 12 bottles @ 750 ML Case = 2.37753 Decimals of .005 or larger should be rounded up. 12 bottles @ .375 ML Case = 1.18877 Example 12.387 would be reported as 12.39. 6 bottles @ 1.5 ML Case = 2.37753 Decimals of .004 and lower should be dropped. 12 bottles @ 1.0 ML Case = 3.17004 Example 12.384 would be reported as 12.38. The total amount of Gallons 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 liters in each bottle = total liters. Total liters Multiplied by .26417 = Factor Converting Liters to Gallons: Liters multiplied by .26417 = Gallons 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. American LegalNet, Inc. www.FormsWorkFlow.com CERAWINE INSTRUCTIONS (Est 11/07)