Mississippi Code Title 97. Crimes § 97-31-15

It shall be unlawful for any railroad company, express company, corporation or other common carrier, or any officer, agent or employee of any of them, or any other person, to deliver any of the alcohol or wine mentioned in this chapter, when transported into or delivered into this state other than to consignees, provided that in any case where the consignee is unable on account of sickness of himself or family, to appear in person and sign for such liquor, the consignee may by written order or authority, authorize some reputable person to sign and receive same for him. In no case shall any delivery be made of a consignment or package of such alcohol or wine as aforesaid without first having such consignee or his lawful agent as aforesaid, sign and deliver to the person in whose charge such consignment or package may be for delivery, a written statement in substance as follows:

“I hereby state that my name is __________; that my postoffice address is __________ Mississippi; that I am more than twenty-one years of age; that I am the consignee to whom the package containing __________ of alcohol or wine (as it may be) was consigned at __________ on the ___ day of __________ 19__________ to be used for (set out the use for which they are to be used). I will not use this liquor in violation of any law of this state.

Signed and dated at __________, Miss., this ___ day of __________ 19___.

In no case shall any railroad company, express company, corporation or common carrier or person, or agent of such railroad company, express company, corporation or other common carrier, or person, be liable for damages for not delivering such alcohol or wine or package containing the same until such statement is executed and delivered as herein provided.

Any person who shall make the statement provided in this section, knowing the same to be false, shall be deemed guilty of a misdemeanor, and, on conviction, shall be fined not less than one hundred dollars nor more than five hundred dollars, and be imprisoned in the county jail not less than thirty days nor more than ninety days, in the discretion of the court.