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

21039001000284

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

141

PART I - APPLICATION

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

DSP-TN-2
DSP-IL-58
NY-I-21645

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)

DIAGEO AMERICAS SUPPLY, INC.
3 WORLD TRADE CENTER STE 41-C

New York NY 10007

CASCADE HOLLOW DISTILLING CO. (Used on label)

4. SERIAL NUMBER (Required)

21R031

5. TYPE OF PRODUCT (Required)

	WINE
	DISTILLED SPIRITS
	MALT BEVERAGE

6. BRAND NAME (Required)

GEORGE DICKEL

8a. MAILING ADDRESS, IF DIFFERENT

7. FANCIFUL NAME (If any)

9. FORMULA

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

(815) 267-4809

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.
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. THE GRAPHICS, SALUTATIONS, DATES, AND ARTWORK PRESENTED ON THIS LABEL MAY BE CHANGED TO PERSONALIZE THIS LABEL. THE PERSONALIZED INFORMATION MAY/MAY NOT BE ETCHED ON THE BOTTLE.*

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 02/08/2021	17. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT (Application was e-filed)	18. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT Carol Gaines

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 02/11/2021	20. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

FOR TTB USE ONLY

QUALIFICATIONS

EACH CONTAINER MUST BE CODED TO INDICATE ACTUAL PLACE OF BOTTLING.
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 SURRENDERED.

CLASS/TYPE DESCRIPTION

BOURBON WHISKY

EXPIRATION DATE (If any)

AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Brand (front) or keg collar
Actual Dimensions: 3.9 inches W X 2.8 inches H

Label Image: Brand (front) or keg collar

Image Type:

Other
Actual Dimensions: 2.87 inches W X 0.93 inches H

Label Image: Other

Image Type:

Back
Actual Dimensions: 2.64 inches W X 3.25 inches H

Label Image: Back

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