OMB No. 1513-0020

OMB No. 1513-0020 (01/31/2009)

FOR TTB USE ONLY

DEPARTMENT OF THE TREASURY

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

APPLICATION FOR AND CERTIFICATION/EXEMPTION OF LABEL/BOTTLE APPROVAL

(See Instructions and Paperwork Reduction Act Notice on Back)

TTB ID

10163001000016

1. REP. ID. NO. (If any)

644

PART I - APPLICATION

2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)

DSP-IN-1

3. SOURCE OF PRODUCT (Required)

	Domestic
	Imported

8. NAME AND ADDRESS OF APPLICANT AS SHOWN ON PLANT REGISTRY, BASIC PERMIT OR BREWER'S NOTICE. INCLUDE APPROVED DBA OR TRADENAME IF USED ON LABEL (Required)

LAWRENCEBURG DISTILLERS INDIANA, LLC
7 RIDGE AVE

LAWRENCEBURG IN 47025

THE BLACK LEMUR DISTILLING COMPANY (Used on label)

4. SERIAL NUMBER (Required)

100105

5. TYPE OF PRODUCT (Required)

	WINE
	DISTILLED SPIRITS
	MALT BEVERAGE

6. BRAND NAME (Required)

GRIND

8a. MAILING ADDRESS, IF DIFFERENT

7. FANCIFUL NAME (If any)

ESPRESSO SHOT

9. EMAIL ADDRESS

10. FORMULA/SOP NO.
(If any)

10-52

11. LAB. NO. & DATE / PREIMPORT NO. & DATE (If any)

18. TYPE OF APPLICATION (Check applicable box(es))

a.	CERTIFICATE OF LABEL APPROVAL
b.	CERTIFICATE OF EXEMPTION FROM LABEL APPROVAL "For sale in _______ only" (Fill in State abbreviation.)
c.	DISTINCTIVE LIQUOR BOTTLE APPROVAL. TOTAL BOTTLE CAPACITY BEFORE CLOSURE ____ _____ (Fill in amount)
d.	RESUBMISSION AFTER REJECTION TTB ID. NO. ______

12. NET CONTENTS

375 MILLILITERS

13. ALCOHOL CONTENT

14. WINE APPELLATION IF ON LABEL

15. WINE VINTAGE DATE IF ON LABEL

16. PHONE NUMBER

(812) 496-0013

17. FAX NUMBER

19. SHOW ANY WORDING (a) APPEARING ON MATERIALS FIRMLY AFFIXED TO THE CONTAINER (e.g., caps, celoseals, corks, etc.) OTHER THAN THE LABLES AFFIXED BELOW, OR (b) BLOWN, BRANDED OR EMBOSSED ON THE CONTAINER (e.g., net contents etc.). THIS WORDING MUST BE NOTED HERE EVEN IF IT DUPLICATES PORTIONS OF THE LABELS AFFIXED BELOW. ALSO, PROVIDE TRANSLATIONS OF FOREIGN LANGUAGE TEXT APPEARING ON LABELS.
¿CONTAINERS WILL BE CODED FOR IDENTIFICATION PURPOSES AT BOTTLING FACILITY. BOTTLE DEPOSIT INFORMATION MAY/MAY NOT APPEAR ON THE LABEL AND/OR CONTAINER. CLOSURE AND/OR CONTAINER AND/OR CAPSULE MAY/MAY NOT CONTAIN BRAND GRAPHICS/LOGOS/EMBOSSING. KOSHER SYMBOL MAY/MAY NOT APPEAR ON LABEL.¿ ¿EITHER/OR BRAND LABEL MAY BE USED.¿

PART II - APPLICANT'S CERTIFICATION
Under the penalties of perjury, I declare; that all statements appearing on this application are true and correct to the best of my knowledge and belief; and, that the representations on the labels attached to this form, including supplemental documents, truly and correctly represent the content of the containers to which these labels will be applied. I also certify that I have read, understood and complied with the conditions and instructions which are attached to an original TTB F 5100.31, Certificate/Exemption of Label/Bottle Approval.
20. DATE OF APPLICATION 06/12/2010	21. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT (Application was e-filed)	22. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT Mary Jane Hayman

PART III - TTB CERTIFICATE
This certificate is issued subject to applicable laws, regulations and conditions as set forth in the instructions portion of this form.
23. DATE ISSUED 06/29/2010	24. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

FOR TTB USE ONLY
QUALIFICATIONS STATUS THE STATUS IS APPROVED. CLASS/TYPE DESCRIPTION RUM SPECIALTIES	EXPIRATION DATE (If any)

AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Brand (front) or keg collar
Actual Dimensions: 3.24 inches W X 4.22 inches H

Label Image: Brand (front) or keg collar

Image Type:

Neck
Actual Dimensions: 3.88 inches W X 1.0 inches H

Label Image: Neck

TTB F 5100.31 (6/2006) PREVIOUS EDITIONS ARE OBSOLETE