Form Att-42 - Affidavit Grapes, Berries, And/or Fruits Seller

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ATT-42 (Rev. 1/13)
GEORGIA DEPARTMENT OF REVENUE
ALCOHOL AND TOBACCO DIVISION
Telephone: (404) 417-4900
E-mail:
ATDIV@dor.ga.gov
AFFIDAVIT
GRAPES, BERRIES, AND/OR FRUITS SELLER
Submit online at
https://gtc.dor.ga.gov
Winery Alcohol License Number _________________________
Receipt Number _________________________
STATE OF ___________________________________
COUNTY OF ___________________________________
We, the undersigned, do hereby certify that we did this _____________ day of ______________________, _____
deliver to ______________________________________________ the following grapes, fruits and/or berries:
(Name of Winery)
REPORT IN POUNDS
Amount Deducted
TYPE
Gross Weight
Net Weight
For Tare
Grapes - Fruits - Berries
We, the undersigned, do further certify that the above listed grapes, fruits, and/or berries were grown only within the State
of Georgia by the undersigned, and declares that this declaration is a true and accurate account of the within described
transaction for the purposes of proper taxation as provided by Section 3-6-50 of the Georgia Alcoholic Beverage Code.
____________________________________
Name of Grower
____________________________________
Address
____________________________________
City
ZIP Code
____________________________________
Signature

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