Header CASES 24/375ml 12/750ml 6/1.5 liter WINE Total Shipment from Page 2 or Attached Schedule247 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. CASESCASES 120/100mlCASES 48/187mlCASES 12/1 liter 4/3 literCASESCASESCASES The total of all shipments must be shown and report filed by the tenth of each month. You must file a zero return even if there are no shipments to report. For any questions regarding this form contact this office by email at WineTax@dor.sc.gov or call (803) 896-1970.Note: A separate report must be filed for each wholesaler to whom wine is shipped.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.STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUEL-BW-I-4 (Rev. 6/15/17) 41761350 WINE IMPORTER REPORT 41761032 I 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 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.Daytime Phone Number Date Email Mail to: SC Department of Revenue, Miscellaneous Tax Section, Columbia, SC 29214-0137Cases Invoiced in Metric Container Sizes Only File Number SSN/FEIN SID Number Period EndedFile Return On or By American LegalNet, Inc. www.FormsWorkFlow.com Month of , 20 Producer Address INVOICED TO: (Name and address of wholesaler) Cases Invoiced in Metric Container Sizes Only INVOICE NUMBER Cases DATE Cases 120/100 ml Cases 48/187 ml Cases 24/375 ml 12/750 ml 6/1.5 liter Cases 12/1 liter 4/3 liter Cases CasesTOTAL 41762030 American LegalNet, Inc. www.FormsWorkFlow.com