Affidavit (Generic)

ATT-112 (Rev 1/13) Page _____ of _____ Pages Due by the 15th of each month following month in which shipments were made Georgia Department of Revenue Alcohol and Tobacco Division Telephone: (404) 417-4900 E-mail: ATDIV@dor.ga.gov DEPT. USE ONLY REPORT OF WINE SHIPMENTS INTO THE STATE OF GEORGIA DURING THE MONTH OF _____________, 20____ Submit online at https://gtc.dor.ga.gov NAME OF WINE SHIPPER GA LICENSE # ADDRESS CITY STATE ZIP CODE INSTRUCTIONS 1. 2. 3. This report must be filed with the Georgia Department of Revenue, on or before the 15th day of each calendar month. List separately, on this form, each invoice of wine shipment made or caused to be made into the State of Georgia during the calendar month for which the report is being filed, giving the information as required by this form. Legible copies of all invoices of wine shipments listed on this report form must be attached. INVOICE REPORT IN LITERS NAME & LOCATION OF 14% OR LESS WHOLESALER TO WHOM SHIPPED ALCOHOL BY VOLUME OVER 14% CASES PER INVOICE ALCOHOL BY VOLUME DEPT USE ONLY WHOLESALER'S E.D.P. CODE DATE NUMBER Grand Total of Shipments to Georgia Wholesalers during the month .................................. I certify, under the penalties for filing false returns, that I have personal knowledge and understanding of statements made in this return and that the figures presented herein, including accompanying materials are true, correct and complete to the best of my knowledge and belief, and are filed in accordance with the law. _____________________________________________ SIGNATURE OF OWNER, PARTNER OR OFFICER ________________________ TITLE _____________ DATE American LegalNet, Inc. www.FormsWorkFlow.com