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Example of Affidavit of Destruction
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NO: _________
Beer/Spirits/Wine Destruction Affidavit
This is to Certify that on _______(DATE)_______
at __(TIME)__AM/PM, the following quantities of BEER
/ WINE / SPIRITS produced by _________(COMPANY)_________,
_______(CITY, STATE)_______, USA was delivered and subsequently
destroyed, by distillation, at Parallel Products, 1620
Bernheim Lane, Louisville, KY 40210.
Producer or Distributor Name: _______________________________
Address: __________________________, City: _____________,
State: ___, Zip: ______
Bill of Lading # __________
| PACKAGE
SIZE |
PACKAGE
TYPE |
TOTAL
QUANTITY |
TOTAL
GALS |
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Producer/Distributor
Company Name |
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Federal
or State Agency Name |
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_________________________
Signature |
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_________________________
Signature |
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_________________________
Title |
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_________________________
Title |
I DECLARE UNDER PENALTIES OF PERJURY
THAT ALL STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE
AND BELIEF.
_________________________
Parallel Products Representative
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