Wine Self Distributor Statement of Cider / Wine Sold to Oregon Retailers Name: Address Month City Select Month Invoice Date Year Select Year Invoice Number OLCC License Number (Barrels) Cider Retailer Product was Sold To (Gallons) Wine 14% and Under (Gallons) Wine Over 14% Name Address City State Zipcode State Zipcode State Zipcode State Zipcode Phone Number OLCC License Number SUMMARY TOTALS FOR RETAIL LICENSEE Name Address City Phone Number OLCC License Number SUMMARY TOTALS FOR RETAIL LICENSEE Name Address City Phone Number OLCC License Number SUMMARY TOTALS FOR RETAIL LICENSEE Name Address City Phone Number OLCC License Number SUMMARY TOTALS FOR RETAIL LICENSEE GRAND TOTALS INSTRUCTIONS - SUBMIT ONE COPY OF THIS REPORT & COPIES OF INVOICES TO: OREGON LIQUOR CONTROL COMMISSION PRIVILEGE TAX SECTION PO BOX 22297 MILWAUKIE, OREGON 97269-2297 Certified True and Correct Under Penalty of Perjury Signature of Person Completing Form Printed Name Date Telephone Number IN ACCORDANCE WITH ORS 471.311 THIS REPORT IS DUE ON OR BEFORE THE 20TH OF THE EACH MONTH SHOWING THE BARRELS OF CIDER OR GALLONS OF WINE SHIPPED TO A RETAILER HOLDING A WINE SELF DISTRIBUTION ENDORSEMENT 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 receipts in a given month. WSD Import (Rev. 07/08) American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR CERTIFICATE OF APPROVAL HOLDERS SHIPPING TO OREGON RETAILERS All Wine and Cider shipped into Oregon to Oregon Retailers 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 - Premises physical 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 Retailer 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. Cider (Barrels) – enter total cider barrels 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 retailer 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 / BARREL CONVERSION INFORMATION Gallon Factors for Common Container Sizes 12 bottles @ .750 Liters = 2.37753 12 bottles @ .375 liters = 1.18877 When reporting Gallons or 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 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 X .26417 = Gallons 31 Gallons = 1 Barrel (Cider) 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. WSD RET Instructions 11/07 American LegalNet, Inc. www.FormsWorkFlow.com