WINERY ANNUAL PRIVILEGE TAX STATEMENT Privilege Tax Report of Malt and Alcoholic Beverages Imported Into or Manufactured Within the State of Oregon Name Month Address City Select Month Year Select OLCC License Number (A) MALT BEVERAGES & CIDER (Barrels) (B) WINE 14% & UNDER (Gallons) (C) WINE OVER 14% (Gallons) $ 2.60 $ 0.67 $ 0.77 Distribution: 1. Tax Paid Removals or Imported Deductions: 2. Exported out of Oregon (Schedule 4) 3. Authorized Deductions (Schedule 5) 4. Small Winery Deduction (Schedule 6) 5. Total Deductions ( Total of Lines 2, 3 & 4) Taxable Amount: 6 . Total Taxable Distribution (Line 1 Minus Line 5) 7. Rate of Tax $ 8. Amount of Tax ( Line 6 x Line 7) $ $ 9. TOTAL TAX (Total of Columns A, B, & C - Line 8) $ 10. Other Additions (or Deductions) $ 11. Penalty - 10% of Delinquent Tax of Late Payment $ 12. Interest - 1% of Delinquent Tax per Month or Fraction of Month $ 13. Audit Adjustments - Charges (or Credits) $ 14. TOTAL TAX, PENALTY and OTHER ITEMS DUE $ (Total of Lines 9 through 13) - Enclose Remittance Certification I certify that I am the duly appointed and qualified (Official Position) _________________________________ of the (Licensee )_______________________________________________ and that the foregoing statement, with accompanying schedules, is a full, true, and complete report of malt and alcoholic beverages imported into or manufactured within the State of Oregon by said licensee during the month or period stated above. (Phone Number) (Signature) (Print 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 . . . . . . . . . . . . . . . . . . . $ WY AN PT STATEMENT (Rev. 11/07) Short . . . . . . . . . . . . . . . . . . . $ American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS WINERY ANNUAL PRIVILEGE TAX STATEMENT All Privilege Tax 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 – Premise address of licensee per licensee number City – City of premise address of licensee per licensee number OLCC License Number – OLCC license number of current certificate Complete the information for each column as needed. Tax Paid Removals / Imported (Line 1) -Taxable product totals from appropriate Schedule which declares taxes due (Schedules 1, 2, 3, 8 & 9) Exported out of Oregon (Line 2) – Export totals from Schedule 4 Authorized Deductions (Line 3) – Authorized deductions totals from Schedule 5 Small Winery Deductions (Line 4) – Small winery deductions totals from Schedule 6 Total Deductions (Line 5) - Totals of Lines 2, 3 & 4 Taxable Amount (Line 6) – Line 1 Minus Line 5 Rate of Tax (Line 7) – Current Rate of tax Amount of Tax (Line 8) - Line 6 multiplied by Line 7 Total Tax (Line 9) – Total of Columns A, B & C – Line 8 Other Additions (or Deductions) (Line 10) – Record error letter received from OLCC Penalty (Line 11) - Penalty due on late reports or errors. Interest (Line 12) - Interest due on late reports or errors. Audit Adjustments (Line 13) - Audit adjustments as indicated on your audit report. Total Tax, Penalty and Other Items Due (Line 14) – Total of Line 9 to Line 13 – 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 Privilege Tax licensees unless you qualify for the Winery Annual Statement. 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. American LegalNet, Inc. www.FormsWorkFlow.com