BEER CERTIFICATE OF APPROVAL HOLDERS 3000 PACIFIC AVE SE PO BOX 43085 SUMMARY TAX REPORT OLYMPIA WA 98504-3085 FORM LIQ-308 E-mail: beerwinetaxes@lcb.wa.gov (Revised 07/15) LCB License No. Licensee Name Location Address City, State & Zip MONTH YEAR If Revised Report (check box) Current licensee lists are available at WSLCB website: http://lcb.wa.gov/taxreporting/licensee-list PART 1: (1) DISTRIBUTOR'S OR IMPORTER'S NON-TAXABLE (2) (ONE LINE TOTAL PER DISTRIBUTOR AND/OR IMPORTER FOR REPORTING MONTH) (3) TOTAL BARRELS CITY (4) TOTAL BARRELS SOLD TO WSLCB LICENSE NO. DISTRIBUTOR'S OR IMPORTER'S NAME @ $8.080 @ $4.782 Total Barrels from all other pages Distributor Shipments (If multiple pages used) (5) (6) TOTAL THIS PAGE PLUS TOTAL FROM Line (5) PART 2: TAXABLE (Shipments for Retailers/Samples/Donations) (7) (8) (9) Tax Rates: Certified True and Correct Under Penalty of Perjury Line (9) X $8.080 = (10) Line (9) X $4.782 = (10) TOTAL BARRELS SHIPPED TO RETAILERS ( LIQ-308-A LINE (6) ) TOTAL BARRELS SHIPPED AS SAMPLES/DONATIONS TOTAL TAXABLE BARRELS (The sum of lines 7 & 8) (10) (11) (12) (13) (14) Taxes Due Current Month PENALTIES for late reporting 2% per month of amounts on line (12) Prior Refund or Balance Due Signature Printed Name Date Telephone No. E-Mail Address Total Amount Due WSLCB USE ONLY Payee Number Amount $ LIQ-308-20-07/15 Office Audit Postmark Date WSLCB USE ONLY Amount Received $ American LegalNet, Inc. www.FormsWorkFlow.com