Producer's Mailing Address: NON-IDENTIFIED BEERThis report must be filed on or before the 10th of the month following date of sale. You must file a zero return even if there are no shipments to report. For any questions about this form contact this office at BeerTax@dor.sc.gov or call (803) 896-1970.S.C. Code of Laws 1976 As Amended: Section 12-54-210 states: Any taxpayer liable for any tax administered by the Department shall keep books, papers, memoranda, records, render statements, make returns and comply with regulations as the Department may prescribe. Persons failing to comply with the provisions of this section must be penalized in an amount to be assessed by the Department not to exceed five hundred dollars for the period covered by the return in addition to any other penalties provided by law. 12-21-1550. Invoices and bills of lading shall be furnished to the Department of Revenue. Prior to shipment into the geographic boundaries of South Carolina to a licensed wholesaler of any beer or wine by a registered producer, the registered producer shall mail by first class mail to the Department of Revenue a correct and complete invoice, showing in detail the items in such shipment by quantity, type, brand and size and the point of origin and the point of destination. Also, prior to or at the time of shipment, a copy of the bill of lading shall be forwarded to the Department of Revenue by first class mail. Upon acceptance of delivery of the shipment by the duly licensed wholesaler, the wholesaler shall furnish the Department of Revenue with a copy of the invoice covering the shipment, with endorsement thereon showing the date, time and place delivery was accepted. 41301037 CANS OR BOTTLES CASES 24/7 OZ. CANS OR BOTTLES CASES 12/12 OZ. CANS OR BOTTLES CASES 24/16 OZ. CANS OR BOTTLES CASES 24/14 OZ. CANS OR BOTTLES CASES 12/32 OZ. CANS OR BOTTLES CASES /8 OZ. CANS OR BOTTLES CASES 24/12 OZ. CANS OR BOTTLES CASES /6 OZ. KEGS 1/4 KEGS 1/2 1350 STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUEL-BW-I-1 (Rev. 6/15/17) 4130 BEER IMPORTER REPORT Place an X in all boxes that apply.Change of Address (Make changes to address below)AMENDED ReturnIf the area below is blank, fill in name and address. Total Shipment from Page 2 or Attached ScheduleI hereby certify that the information contained in this report has been examined by me and to the best of my knowledge is correct and complete. Name (Print)Title Signature Daytime Phone Number Date EmailNote: A separate report must be filed for each wholesaler to whom beer is shipped. Mail to: SC Department of Revenue, Miscellaneous Tax Section, Columbia, SC 29214-0137 File Number SSN/FEIN SID Number Period EndedFile Return On or By American LegalNet, Inc. www.FormsWorkFlow.com Page 2 Producer AddressNON-IDENTIFIED BEER INVOICE NUMBERDATE 41302035 Month of , S.C. WHOLESALER SOLD TOCANS OR BOTTLES CASES 24/7 OZ. CANS OR BOTTLES CASES 12/12 OZ. CANS OR BOTTLES CASES 24/16 OZ. CANS OR BOTTLES CASES 24/22 OZ. CANS OR BOTTLES CASES 12/32 OZ. CANS OR BOTTLES CASES 12/40 OZ. CANS OR BOTTLES CASES 24/12 OZ. CANS OR BOTTLES CASES 30/12 OZ. KEGS 1/4 KEGS 1/2 TOTALS American LegalNet, Inc. www.FormsWorkFlow.com