OMB No. 1513-0020

OMB No. 1513-0020

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

23165001000706

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

149

PART I - APPLICATION

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

DSP-MO-20069

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)

Old Ozarkian Distillery, Old Ozarkian Distillery LLC
1615 HACKBERRY DR

Union MO 63084

4. SERIAL NUMBER (Required)

23A823

5. TYPE OF PRODUCT (Required)

	WINE
	DISTILLED SPIRITS
	MALT BEVERAGE

6. BRAND NAME (Required)

BOURBEUSE VALLEY MAPLE SYRUP FLAVORED BOURBON WHISKEY

8a. MAILING ADDRESS, IF DIFFERENT

7. FANCIFUL NAME (If any)

9. FORMULA

1543466

10. GRAPE VARIETAL(S) (Wine Only)

N/A

14. 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. ______

11. WINE APPELLATION (If on label)

12. PHONE NUMBER

(314) 799-1738

13. EMAIL ADDRESS

15. 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.

S.D.G. are initials for the Latin words Soli Deo Gloria which means "All Glory to God."

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.
16. DATE OF APPLICATION 06/14/2023	17. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT (Application was e-filed)	18. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT Jonathan Downard

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.
19. DATE ISSUED 07/27/2023	20. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

FOR TTB USE ONLY

QUALIFICATIONS

Because the alcohol content does not impact the class and type of this product, the COLA is approved despite discrepancy between the alcohol content stated in your formula and on your label. (Formula ID 1543466, Formula Tab, Yield Summary shows that this product was bottled at or between 30% to 40% ALC/VOL - 60 to 80 Proof. Replace "50% ALC/VOL" and "100 PROOF" with figures at or between 30% to 40% ALC/VOL - 60 to 80 Proof when labels are printed to conform to the approved formula.)
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 APPROVED.

CLASS/TYPE DESCRIPTION

OTHER WHISKY (FLAVORED)

EXPIRATION DATE (If any)

AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Brand (front) or keg collar
Actual Dimensions: 3 inches W X 3.5 inches H

Label Image: Brand (front) or keg collar

Image Type:

Back
Actual Dimensions: 3 inches W X 3.5 inches H

Label Image: Back

TTB F 5100.31 (06-2016) PREVIOUS EDITIONS ARE OBSOLETE