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Schedule C (Form Bt-Fw) - Alcoholic Beverages Tax Wine Shipped Outside Of Connecticut

Form BT-FW

DEPARTMENT OF REVENUE SERVICES

STATE OF CONNECTICUT

Schedule C (Farm Wineries)

PO Box 5034

Hartford CT 06102-5034

Alcoholic Beverages Tax

Rev. 11/01

Wine Shipped Outside of Connecticut

Shipments made into the State of: _____________________________ For the month of: ________________________ , _________

Shipping Company Name: __________________________________________ Address: ________________________________________

1. Use this form when completing Form O-255 FW, Farm Winery Alcoholic Beverages Tax Return .

2. Use this form to report each shipment, including returns, of wine to a point outside of Connecticut during the month listed above.

3. Do not include wines that were not shipped outside of Connecticut.

4. Use a separate form for each state into which shipments or returns were made during the month listed above.

5. This form must be filed in duplicate.

Still Wines

Not Over 21% Alcohol

Wine Gallons

Fortified Wines

Name and Address

Over 21% Alcohol

Produced by Wineries

Produced by Small

Wholesaler or Distributor

and Sparkling Wines

Other Than

Wineries

(Producing 55,000

Sold or Delivered to

Date Shipped

Invoice Number

Small Wineries

Wine Gallons

wine gallons or less per year)

Schedule C (Form Bt-Fw) - Alcoholic Beverages Tax Wine Shipped Outside Of Connecticut