PLCB-1676 9/05 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD LICENSE NO. LIMITED WINERY MONTHLY REPORT OF OPERATIONS TELEPHONE ( BUREAU OF LICENSING FOR MONTH OF ) 20 ADDRESS OF REPORTING LOCATION BULK GOODS (See Instructions 1, 2, and 3 on reverse) GALLONS GALLONS 11. Opening Inventory (Bulk Goods). ADDITIONS TO BULK STORAGE: 22. Transfers to bulk storage from fermentation. 33. Transfers to bulk storage from bottled goods. 44. Transfers into bulk storage of reporting location from other authorized location(s). 55. Transfers to bulk storage from other limited wineries (indicate name of wineries and gallons received from each in Remarks). 66. Other additions to bulk storage (explain in Remarks on reverse). 77. TOTAL ENTER TOTAL OF LINES 1, 2, 3, 4, 5, and 6 HERE REMOVALS FROM BULK STORAGE: 88. Transfers to bottled goods from bulk storage. 99. Shipments in bulk to other authorized location(s). 10. Shipments out of bulk storage to other limited wineries (indicate name of wineries and gallons shipped to each in Remarks). 11. Evaporation or spillage (explain amounts in Remarks on reverse). 12. Other removals from bulk storage (explain in Remarks on reverse). 13. TOTAL ENTER TOTAL OF LINES 8, 9, 10, 11 and 12 HERE 14. Ending Inventory (Bulk Goods). (Subtract Line 13 from Line 7) BOTTLED GOODS (See Instructions 2, 4, on reverse) 15. Opening Inventory (Bottled Goods). ADDITIONS TO BOTTLED GOODS: 16. Transfers to bottled goods from bulk storage. 17. Bottled goods transferred into reporting location from other authorized location(s). 18. Other additions to bottled goods (explain in Remarks on reverse). 19. TOTAL ENTER TOTAL OF LINES 15, 16, 17 and 18 HERE REMOVALS FROM BOTTLED GOODS: 20. On-premise bottled goods sales. 21. Samples (include removals for home use). 22. Shipments to PLCB. 23. Shipments to others in Pennsylvania. 24. Shipments to points outside Pennsylvania. 25. Bottled goods transferred out from reporting location to other authorized location(s). 26. Transfers from bottled goods to bulk storage. 27. Breakage or leakage. 28. Other removals from bottled goods (explain in Remarks on reverse). 29. TOTAL ENTER TOTAL OF LINES 20, 21, 22, 23, 24, 25, 26, 27 and 28 HERE 30. Ending Inventory (Bottled Goods). (Subtract Line 29 from Line 19) FERMENTATION 31. Amount in fermenters last day of the month. SUMMARY OF MATERIALS RECEIVED AND USED IN WINE PRODUCTION (See Instruction 5 on reverse) PA. GROWN OUT-OF-STATE Grapes: Uncrushed (pounds) Juice/Concentrate (gallons) (See Instruction 5 on reverse) Fruits other than Grapes: Total (pounds) Juice/Concentrate (gallons) (See Instruction 5 on reverse) CERTIFICATION: I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904 and 47 P.S. §5-504(b), that the foregoing answers and statements herein are true and complete to the best of my knowledge and belief. SIGNATURE TITLE (LICENSEE OR AUTHORIZED AGENT) DATE American LegalNet, Inc. www.FormsWorkflow.com REMARKS (use additional sheets if necessary.) INSTRUCTIONS This report shall be filed on or before the 15th day of the month following the month for which the report is compiled. Reports shall be filed as follows: original to the Pennsylvania Liquor Control Board, P.O. Box 8940, Harrisburg, Pennsylvania 171058940, and duplicate retained on the licensed premises for a period of two years. A separate report must be filed monthly for each authorized location (main winery and extension(s)). All applicable transactions for each location must be detailed including inter-premise transfers in the appropriate spaces. All quantities reported should be in terms of standard wine gallons or in pounds where indicated. 1. Bulk wine is defined as wine which has undergone and completed primary alcoholic fermentation. Enter the “book inventory” of bulk wine on hand the first day of the month. This must be the same amount as the ending inventory for the preceding month. Adjustments in inventory figures resulting from an actual physical inventory should be indicated on either Line 6 or Line 11 of this form accompanied by an appropriate explanation. 2. Other authorized locations applies to Additional Board Approved Locations (outlets). Shipments from the main winery to outlets, or shipments from outlets to main winery should be entered in the appropriate spaces. 3. Bulk wine receipt and removal transactions between licensed PA Limited Wineries shall be reported on Lines 5 and 10 respectively, of this form accompanied by an appropriate explanation in the remarks section. 4. Enter the “book inventory” of bottled goods on hand the first day of the month. Do not include wine in bottles undergoing secondary fermentation for the purpose of producing sparkling wines. Such products shall be included in bulk wine totals until they are transferred to bottled goods inventory as finished products. The book inventory must be the same amount as the ending inventory for the preceeding month. Adjustments in inventory figures resulting from an actual physical inventory should be indicated on Line 18 or Line 28 of this form accompanied by an appropriate explanation. 5. All Limited Wineries are required to complete the “Summary of Materials Received and Used in Wine Production”. For the purposes of this report, juice concentrate should be converted to reconstituted (water added) gallonage. 6. Always use whole numbers when reporting figures. Holders of Limited Winery Licenses are reminded that in accordance with the PA Liquor Code and PLCB regulations, complete and accurate records of all operations including the source of all materials used in the production of wine as well as copies of all required state and federal forms must be maintained on the licensed premises and at all times be open to inspection by representatives of the Board and the Pennsylvania State Police, Bureau of Liquor Control Enforcement. American LegalNet, Inc. www.FormsWorkflow.com