OMB No. 1513-0020 (07/31/2015)
FOR TTB USE ONLY
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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)
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TTB ID
15320001000480
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1. REP. ID. NO. (If any)
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CT
129
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OR
22
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PART I - APPLICATION
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2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)
DSP-KY-16
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3. SOURCE OF PRODUCT (Required)
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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)
DIAGEO AMERICAS SUPPLY, INC.
3860 FITZGERALD RD
LOUISVILLE
KY
40216
T.H.L. WHISKEY CO. (Used on label)
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4. SERIAL NUMBER (Required)
15U041
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5. TYPE OF PRODUCT (Required)
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6. BRAND NAME (Required)
THE HILHAVEN LODGE
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8a. MAILING ADDRESS, IF DIFFERENT
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7. FANCIFUL NAME (If any)
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9. EMAIL ADDRESS
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10. GRAPE VARIETAL(S) (Wine Only)
N/A
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11. FORMULA
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18. TYPE OF APPLICATION (Check applicable box(es))
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12. NET CONTENTS
750 MILLILITERS
1.75 LITERS
1 LITER
200 MILLILITERS
375 MILLILITERS
50 MILLILITERS
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13. ALCOHOL CONTENT
40
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14. WINE APPELLATION IF ON LABEL
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15. WINE VINTAGE DATE IF ON LABEL
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16. PHONE NUMBER
(202) 213-3757
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17. FAX NUMBER
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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.
CONTAINERS WILL BE CODED FOR IDENTIFICATION PURPOSES AND BOTTLING FACILITY. BOTTLE DEPOSIT INFORMATION MAY/MAY NOT APPEAR ON THE LABEL AND/OR CONTAINER. CLOSURE AND/OR CONTAINER MAY/MAY NOT CONTAIN BRAND GRAPHICS/LOGOS/EMBOSSING. KOSHER SYMBOL MAY/MAY NOT APPEAR ON LABEL.
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PART II - APPLICANT'S CERTIFICATION
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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.
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20. DATE OF APPLICATION
11/16/2015
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21. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
(Application was e-filed)
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22. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT
DEBORAH
RINGO
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PART III - TTB CERTIFICATE
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This certificate is issued subject to applicable laws, regulations and conditions as set forth in the instructions portion of this form.
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23. DATE ISSUED
01/07/2016
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24. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
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FOR TTB USE ONLY
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QUALIFICATIONS
Other (CLASS AND TYPE DESIGNATION MUST COMPLY WITH 27 CFR 5.22(b)(iii) WHEN NEW LABELS ARE PRINTED.)
NO MORE USE-UPS WILL BE GRANTED.
This certificate is operative for the release of not more than the following number of bottle cases/ kegs. (2500 9 LITER CASES)
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 STRAIGHT BLENDED WHISKY
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EXPIRATION DATE (If any)
07/07/2016
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AFFIX COMPLETE SET OF LABELS BELOW
Image Type:
Brand (front) or keg collar
Actual Dimensions: 2.24 inches W X 2.56 inches H
Image Type:
Brand (front) or keg collar
Actual Dimensions: 2.24 inches W X 1.81 inches H
Image Type:
Back
Actual Dimensions: 2.24 inches W X 2.56 inches H
Image Type:
Neck
Actual Dimensions: 4.72 inches W X 0.51 inches H
TTB F 5100.31 (07/2012) PREVIOUS EDITIONS ARE OBSOLETE