Standard Price Filing Form {D-101-A}

D-101-A North Carolina Standard Price Filing Form SUBMITTED TO THE NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION Submit One Form Per Size Brand Name Classification American or Imported Distilled By Name & Address of Bottler Shipping Point for N. C. Date Submitted *** NORTH CAROLINA BROKER: Bottle/VAP UPC (12 digits) Shipping Container Code (SCC) (14 digits) Control State Code (Required) North Carolina Code Type Age Proof / Alcohol Content Size Weight Per Case Cases Per Pallet Miniature Only - Bottles Per Case: Miniature Only - Bottles Per Sleeve: Effective Date Size and Bottles Per Case Case Cost FOB Freight Cost Case Cost LESS Bailment Bailment 1.75 Liter 6 .750 Liter 12 .375 Liter 24 50 ML (Miniature) 120 1.60 1.855650 .80 1.60 1.855650 .80 1.60 1.855650 .80 1.60 1.855650 .80 Sub Total Case Cost Multipy By: Case Cost to 6 decimals Add Surcharge Result: Divide by bottles Per Case Add Rehabilitation Add Local Bottle Charge Total 4 Decimals .05 .05 .05 .05 .05 .05 .01 .01 Retail Bottle Price MXB PRICE __________________ REMARKS: Sleeve / Pack Price This information constitutes CONFIDENTIAL PROPRIETARY INFORMATION. G.S.132-1.2(1)-(4),G.S.66-152(3) It is hereby warranted that the case price shown hereon is true, correct and that the FOB will be continuously maintained throughout the quotation period. It is further warranted that the freight cost shown hereon does not exceed cost of delivery to North Carolina. COMPANY / SUPPLIER ADDRESS SIGNATURE OF EXECUTIVE OFFICER Rev 8/01/2011 Print name: American LegalNet, Inc. www.FormsWorkFlow.com