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Form Bt-20 - Alcoholic Beverage Tax - Sealed Neck Bottle Destruction Certificate - 2001 Page 2

Column C

Alcohol

Necks

(Gallons)

Alcohol

Necks

Gallons

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8

Total

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8

Column D (Summary of Columns A, B, and C)

From Column A - Beer

From Column A - Cider

From Column A - Other

From Column B - Liquor

From Column B - Wine: Under 21%

From Column B - Wine: Sparkling

From Column C - Alcohol

Total Gallons

Declaration

I declare under penalty of law that I have examined this return and, to the best of my knowledge and belief, it is true,

complete, and correct. I understand that the penalty for willfully delivering a false return to DRS is a fine of not more

than $5,000, or imprisonment for not more than five years, or both. The declaration of a paid preparer other than the

taxpayer is based on all information of which the preparer has any knowledge.

_________________________________________________

_____________________________

______________

Signature of Taxpayer

Title

Date

BT-20 Back (Rev. 09/01)

Form Bt-20 - Alcoholic Beverage Tax - Sealed Neck Bottle Destruction Certificate - 2001 Page 2