VERMONT DEPARTMENT OF TAXES PO BOX 547 MONTPELIER, VT 05601-0547 STATEMENT OF VINOUS BEVERAGES SOLD TO A VERMONT DEALER For month of __________________, 20______ File this report on or before the 20th of each month. Distributor Distributor’s Address City State ZIP Code City State ZIP Code VT Dealer (Use a separate sheet for each Vermont dealer.) Address Include Transfers and/or Credits to VT Dealers NUMBER OF CASES BY VOLUME INVOICE GAL 4 Number 1/2 GAL 6 Date 128 OZ 64 OZ MAG QTS OR LITRE 5THS PTS 10THS 20THS 6 12 12 24 24 48 48 - 52 27 - 33.9 19 - 26.9 15 - 18.9 11 - 14.9 0 - 10.9 OZ OZ OZ OZ OZ OZ JERO 4 LITRE 4 4 101.4 104 OZ 135 OZ TOTAL GALLONS TOTAL CASES I declare, under penalties of perjury, that this return (including any accompanying schedules and statements) is true, correct, and complete to the best of my knowledge. Distributor Signature Date Prepared by (Print or Type) Title Rev. 10/07 Form VB-3 American LegalNet, Inc. www.FormsWorkFlow.com