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Instructions For Form Ttb F 5120.25 - Application To Establish And Operate Wine Premises Page 3

Sample- Corporation or Limited Liability Company

ABC Winery

Serial #1

Page 1

Serial Number 1

Name and address:

ABC Winery, Inc.

dba ABC Winery

123 Main Street

Somewhere, MO 54321

Business Organization – ABC Winery, Inc. organized in the State of Missouri.

John D. Doe, President/Treasurer

50% ownership

321 Elm Street

Somewhere, MO 54321

Jane D. Doe, Vice-President/Secretary

50% ownership

321 Elm Street

Somewhere, MO 54321

(Include copies of organizational or corporate documents i.e. Certificate and/or, Articles of

Incorporation, Stock Certificates, By-Laws, Partnership or LLC Operating Agreement)

Wine Premises

The winery is located on a 157 acre farm. Starting at point A, 175 ft east to point B; 150 ft

south to point C; 100 ft west to point D; 75 ft north to point E; 75 ft west to point F; 75 ft north to

starting point. The first floor of the building is 5000 sq. ft and will be used for producing,

storing and selling wine. The second floor is used for offices. The building is a concrete

structure with a shingle roof. There are no windows and 2 exterior doors secured with dead

bolt locks. Attached is a drawing of the wine premises.

Disclosure - Not Applicable

Trade Name - ABC Winery. Trade name has been registered with the State of MO

Spirits Operations – None

Wine Bond has been secured through National Insurance in the amount of $1000.

Volatile Fruit-Flavor Concentrate Operations – None

Other Operations - None

NOTE:

Label the attached drawing: ABC Winery, SN 1, Page 2

Instructions For Form Ttb F 5120.25 - Application To Establish And Operate Wine Premises Page 3