Licensing and Regulation PO Box 43098 Olympia, WA 98504-3098 Phone: (360) 664-1600 FAX: (360) 753-2710 www.lcb.wa.gov License Number UBI Number Trade Name ADDENDUM - BEER AND WINE TAX PAYMENT AND REPORTS Instructions and Information 1. Please complete this form and mail the original to the Liquor Control Board at the above address. You are advised to keep a copy for your records. 2. Note: If you have questions please call the Tax Desk at 360-664-1721, option 1. Applies To: Domestic Winery Wine Importer Wine Distributor Wine Certificate of Approval Domestic Brewery Domestic Brewery - Brand Owner Microbrewery Beer Importer Beer Distributor Beer Certificate of Approval Public House Interstate Common Carrier Wine Shippers Wine Authorized Representative Beer Authorized Representative In Accordance With: RCW 66.24.210, WAC 314-19-015(5) RCW 66.24.203, WAC 314-19-015(4) RCW 66.24.210, WAC 314-19-015(3) RCW 66.24.206, WAC 314-19-015(7) RCW 66.24.270, WAC 314-19-015(5) RCW 66.24.270, WAC 314-19-015(6) RCW 66.24.270, WAC 314-19-015(5) RCW 66.24.261, WAC 314-19-015(4) RCW 66.24.290, WAC 314-19-015(3) RCW 66.24.270, WAC 314-19-015(7) RCW 66.24.580, RCW 66.24.290, WAC 314-19-015(11) RCW 66.24.210, RCW 66.24.270, WAC 314-27-010 RCW 66.12.190, WAC 314-19-015(13) RCW 66.24.210, WAC 314-19-015(10) RCW 66.24.270, WAC 314-19-015(10) It is hereby agreed: A report, under oath, will be furnished to the Washington State Liquor and Cannabis Board on or before the 20th day of each month, on a form prescribed by the Board showing the quantity of beer/wine sold and/or delivered in Washington. Approved annual filers must postmark their report on or before January 20th of the year following activity. All taxes will be paid at the time and in the amounts as may be prescribed by Washington laws. All agents, representatives and sales corporations maintained or affiliated with the applicant will faithfully comply with the Washington State Liquor and Cannabis Board's rules and regulations and the liquor laws of the State of Washington pertaining to the sale of liquor. Print Signature: Firm/Company: Date: Title: Email: Phone: ( )-( )-( ) LIQ300 7/15 American LegalNet, Inc. www.FormsWorkFlow.com