FORM C-215 (02/09) TABC USE ONLY TEXAS WINERY REPORT ENTRY Monthly Report of Wine Bottled, Received and Disposed of SCHEDULES During the Month/Year of: SUMMARY **REPORT IS DUE ON OR BEFORE THE 15TH DAY OF THE MONTH FOLLOWING EACH REPORTING PERIOD** TRADE NAME: ADDRESS: CITY: PERMIT NUMBER: LOCATION (check one) PHONE NUMBER: G WET DRY* Bottled Wine Gallons SUMMARY OF TAXES DUE WINE 14% AND LESS WINE OVER 14% - 24% SPARKLING WINE 1. INVENTORY, BEGINNING OF MONTH (From Line 5 on Prior Monthly Report) 2. WINE BOTTLED ON PREMISE (Schedule C) 3. WINE RECEIVED FROM OTHER SOURCE (Schedule A) 4. TOTAL (Lines 1,2 & 3) 5. INVENTORY, END OF MONTH 6. EXEMPTIONS (Schedule B) 7. TOTAL (Line 5 + 6) 8. WINE SUBJECT TO TAX (Line 4 - 7) 9. TAX RATES $0.204 $0.516 $ 10. AMOUNT OF TAXES (Line 8 x 9) $0.408 $ $ TABC USE ONLY 11. GROSS TAXES DUE 12. LESS 2% $ (Total of Line 10) $ (If payment is received by due date) 13. LESS AUTHORIZED CREDITS (Attach letter of authorization) 14. TAXES DUE STATE $ $ *DRY STATUS LOCATION, Wine sold or dispensed is bottled in this state and at least 75 percent by volume fermented juice of grapes or other fruit grown in this state or a lesser percentage established by the Department of Agriculture. AFFIRMATION, Under penalty of perjury, I swear I am an officer or authorized representative of the above Permittee, and I have examined this report, and confirm it is true, correct, and complete. Signature Title E-Mail Date INSTRUCTIONS: Prepare the report in duplicate, mail the original to the T.A.B.C., PO Box 13127, Austin, TX 78711-3127 on or before the 15th of each month, following the month for which the report is made. Retain one copy for your files for a period of four years. As long as your permit remains active, you must timely file a report even if no business was conducted. For assistance, please contact the Excise Tax Department at (512) 206-3342 or excise.tax@tabc.state.tx.us. Forms are available on our website at (www.tabc.state.tx.us). Page 1 American LegalNet, Inc. www.FormsWorkflow.com FORM C-215 (02/09) SCHEDULE A - Bottled Wine Received INVOICE DATE INVOICE NUMBER TRADE NAME BOTTLED WINE GALLONS (attach invoices) WINE 14% AND LESS CITY / STATE WINE OVER 14% - 24% WINE SPARKLING CARRIER MAKING DELIVERY TOTAL RECEIVED (To line 3, page 1) SCHEDULE B - Bottled Wine Disposed Of: (invoices must be submitted to support each entry) SALES TO TEXAS WHOLESALERS OR OTHER WINERIES EXPORTS OUT-OF-STATE OTHER ALLOWABLE EXEMPTIONS TOTAL EXEMPTIONS (To line 6, page 1) SCHEDULE C - Wine Bottled from Bulk (monthly total only) NOTE: A separate daily bottling record itemizing total cases bottled, bottles per case and size of containers must be prepared and retained in your files. Bulk wine may only be purchased from the holders of a Winery permit or Nonresident Seller's permit. All receipts and sales of bulk wine must be retained in your files to be verified by a representative of the Commission upon request. TOTAL GALLONS BOTTLED BY CLASS (To line 2, page 1) American LegalNet, Inc. www.FormsWorkflow.com Page 2 FORM C-215 (02/09) SUPPLEMENTAL SCHEDULE: A (circle one) or B Gallons INVOICE DATE INVOICE NUMBER TRADENAME CITY / STATE WINE 14% AND LESS WINE OVER 14% - 24% WINE SPARKLING CARRIER MAKING DELIVERY TOTAL American LegalNet, Inc. www.FormsWorkflow.com