1350 STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUE L-BW-I-4 REPORT OF WINE SHIPMENTS INTO SOUTH CAROLINA (Rev. 6/11/08) 4176 Office Use Only Producer's Mailing Address: File Number: Period Covered: 14-1304 Phone Number _______________________________________ WINE Total Shipment from Page 2 or Attached Schedule Cases Invoiced in Metric Container Sizes Only CASES 120/100ml CASES 48/187ml CASES 24/375ml 12/750ml 6/1.5 liter CASES 12/1 liter 4/3 liter CASES CASES CASES CASES 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. S 12-21-1550. Invoices and bills of lading shall be furnished to the Department of Revenue. S 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. The total of all shipments must be shown and report filed with the South Carolina Department of Revenue, Miscellaneous Tax Section, Columbia, SC 29214-0137, by the tenth of each month. Phone (803) 896-1970 Note: A separate report must be filed for each wholesaler to whom wine is shipped. 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. Signature Title Date 41761024 American LegalNet, Inc. www.FormsWorkFlow.com 41762022 American LegalNet, Inc. www.FormsWorkFlow.com TOTAL (Name and address of wholesaler) INVOICED TO: Producer INVOICE NUMBER DATE Cases 120/100 ml Month of Cases 48/187 ml Cases 24/375 ml 12/750 ml 6/1.5 liter Cases 12/1 liter 4/3 liter Cases Cases Invoiced in Metric Container Sizes Only Address , 19 Cases Cases