OMB No. 1513-0020  (07/31/2015)
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
12264001000364

1. REP. ID. NO. (If any)
CT
901

OR
29

PART I - APPLICATION
2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)
BR-MO-20000
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)

ANHEUSER-BUSCH, LLC
1 BUSCH PL

SAINT LOUIS MO 63118

LATROBE BREWING CO. (Used on label)
4. SERIAL NUMBER (Required)
12RA01

5. TYPE OF PRODUCT (Required)
WINE
DISTILLED SPIRITS
MALT BEVERAGE

6. BRAND NAME (Required)
ROLLING ROCK BLACK ROCK
8a. MAILING ADDRESS, IF DIFFERENT
7. FANCIFUL NAME (If any)
9. EMAIL ADDRESS
ROSEMARY.SCHWARTZ@ANHEUSER-BUSCH.COM
10. GRAPE VARIETAL(S)
(If any)
11. FORMULA
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
12 FL. OZ.
1 PT. 6 FL. OZ. (22 FL. OZ.)
13. ALCOHOL CONTENT
6.0% abv
14. WINE APPELLATION IF ON LABEL
15. WINE VINTAGE DATE IF ON LABEL
16. PHONE NUMBER
(314) 577-2693
17. FAX NUMBER
(314) 445-3766
19. SHOW ANY INFORMATION THAT IS BLOWN, BRANDED, OR EMBOSSED ON THE CONTAINER (e.g., net contents) ONLY IF IT DOES NOT APPEAR ON THE LABELS AFFIXED BELOW. ALSO, SHOW TRANSLATIONS OF FOREIGN LANGUAGE TEXT APPEARING ON LABELS.
FRESHNESS DATE CODE AND WEBSITE. KOSHER SYMBOL, IF APPLICABLE TO BRAND. ANY WORDING REQUIRED BY STATES (ALCOHOL CONTENT, DEPOSIT LANGUAGE). ¿RETURNABLE¿ OR ¿NON-RETURNABLE¿ MAY APPEAR ON BOTTLE LABELS. PLACE OF PRODUCTION CODING.
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
09/20/2012
21. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
(Application was e-filed)
22. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT
ROSEMARY SCHWARTZ
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
09/27/2012
24. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
Authorized Signature

FOR TTB USE ONLY
QUALIFICATIONS
TTB has not reviewed this label for type size, characters per inch or contrasting background. The responsible industry member must continue to ensure that the mandatory information on the actual labels is displayed in the correct type size, number of characters per inch, and on a contrasting background in accordance with the TTB labeling regulations, 27 CFR parts 4, 5, 7, and 16, as applicable.
EACH CONTAINER MUST BE CODED TO INDICATE ACTUAL PLACE OF BOTTLING.

STATUS
THE STATUS IS APPROVED.

CLASS/TYPE DESCRIPTION
BEER

EXPIRATION DATE (If any)

AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Brand (front)
Actual Dimensions: 2.81 inches W X 3.21 inches H


Label Image: Brand (front)


Image Type:

Back
Actual Dimensions: 3.07 inches W X 3.10 inches H


Label Image: Back


Image Type:

Neck
Actual Dimensions: 4.0 inches W X 1.95 inches H


Label Image: Neck




TTB F 5100.31  (7/2012) PREVIOUS EDITIONS ARE OBSOLETE