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
12307001000034

1. REP. ID. NO. (If any)
CT
649

OR
43

PART I - APPLICATION
2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)
DSP-TN-4
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)

JACK DANIEL DISTILLERY, LEM MOTLOW PROPRIETOR, BROWN-FORMAN CORPORATION
280 LYNCHBURG HWY

LYNCHBURG TN 37352

JACK DANIEL DISTILLERY (Used on label)
4. SERIAL NUMBER (Required)
120118

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

6. BRAND NAME (Required)
JACK DANIEL'S
8a. MAILING ADDRESS, IF DIFFERENT
7. FANCIFUL NAME (If any)
UNAGED RYE
9. EMAIL ADDRESS
 
10. GRAPE VARIETAL(S) (Wine Only)
N/A
11. FORMULA
1172912
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
750 MILLILITERS
13. ALCOHOL CONTENT
40
14. WINE APPELLATION IF ON LABEL
15. WINE VINTAGE DATE IF ON LABEL
16. PHONE NUMBER
(502) 774-7324
17. FAX NUMBER
(502) 774-7188
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.
NET CONTENTS IS BLOWN INTO THE BOTTLE. "JACK DANIEL" IS BLOWN INTO THE BOTTLE FOUR TIMES.
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
11/02/2012
21. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
(Application was e-filed)
22. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT
MARY DILLARD
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
11/28/2012
24. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
Authorized Signature

FOR TTB USE ONLY
QUALIFICATIONS
Other (Labels which are not an integral part of the bottle (see class and type designation) shall be affixed to bottles in such manner that they cannot be removed without thorough application of water or other solvents)
This certificate is operative for the release of not more than the following number of bottle cases / kegs. (20,845 cases)
NO MORE USE-UPS WILL BE GRANTED.
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.

STATUS
THE STATUS IS EXPIRED.

CLASS/TYPE DESCRIPTION
OTHER SPECIALTIES & PROPRIETARIES

EXPIRATION DATE (If any)
05/28/2013

AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Brand (front) or keg collar
Actual Dimensions: 04.13 inches W X 01.02 inches H


Label Image: Brand (front) or keg collar


Image Type:

Brand (front) or keg collar
Actual Dimensions: 06.10 inches W X 01.26 inches H


Label Image: Brand (front) or keg collar


Image Type:

Back
Actual Dimensions: 02.32 inches W X 01.30 inches H


Label Image: Back




TTB F 5100.31  (07/2012) PREVIOUS EDITIONS ARE OBSOLETE