Total liters shipped (From attached schedule) OUT OF STATE WINE SHIPPER TAX REPORT 1. 2. 3. 4. 5. 6. Excise Tax Due (Multiply line 1 by $.2535 rate per liter) WINES SHIPPED DIRECT TO SOUTH CAROLINA RESIDENTS *See back of this form for Schedule 1.I hereby certify that the information contained in this report (including accompanying schedules and statements) has been examined by me and to the best of my knowledge is correct and complete.For questions regarding this form email this office at WineTax@dor.sc.gov or call (803) 896-1970. You must file a zero return even if there is no tax due in the period.L-2166 (Rev. //1) 4316 $ $$ Total Tax Due (Add lines 2 and 3) Penalty and Interest Additional tax due on wines shipped (Multiply line 1 by $.0507)TOTAL WINE TAX, PENALTY AND INTEREST DUE (Total of lines 4 and 5.) $ $43161041 STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUEPlace an X in all boxes that apply. . . . 1350Change of Address (Make changes to address below)AMENDED Return If the area below is blank, fill in name and address. Name (Print)Title Signature Daytime Phone Number Date Email . . . . . Mail to: SC Department of Revenue, Miscellaneous Tax Section, Columbia SC 29214-0137. FEIN File NumberFile Return On or ByPeriod Ended SID Number American LegalNet, Inc. www.FormsWorkFlow.com Date Invoice numberCustomer name Customer address Brand name Bottles size (volume)Price per bottleTotal liters shippedNo. bottles shippedTotal liters of wine shipped to SC residentsSchedule 1 - WINES SHIPPED DIRECT TO SOUTH CAROLINA RESIDENTS 43162049 American LegalNet, Inc. www.FormsWorkFlow.com