OUT-OF-STATE WINE SHIPPER MONTHLY TAX REPORT 6601 Campstool Rd., Cheyenne, Wyoming 82002-0110 Name of Direct Shipper For the Month of ____________________, 201_____ Address License # Date Submitted _______/_______/_______ This report along with copies of all invoices shipped into Wyoming must be filed monthly so as to arrive at the Department of Revenue Liquor Division on or before the 10th of the following month. Invoices Shall Be Submitted With Report Address Shipped To # of Bottles Invoice # Volume In Liters Price of Wine Per Invoice Total Price of WINE Shipped into Wyoming (enter as "Total Report Price" below) Attach additional sheets, if necessary. Report the price of WINE invoiced only. DO NOT report shipping, packaging, taxes or any other costs. $ Times (X) .12 For Official Use Only 212040 212121 710500 Total Report Price Total Tax Due at 12% $ Affidavit of Authenticity: I understand that by signing this return I affirm all information shown is true and correct to the best of my knowledge. I understand that this statement is made subject to the penalties described in W.S. 12-2-204. I understand I am to retain all ordinary business records pertaining to this return for at least 3 years and allow the Department of Revenue Liquor Division to audit such records upon reasonable request. Owner or Officer Mail completed report and any payments to: Wyoming Liquor Division Attn: Wine Direct Ship Coordinator 6601 Campstool Road Cheyenne, WY 82002-0110 American LegalNet, Inc. www.FormsWorkFlow.com