Form Spt 115 - Notice Of Delinquent Retailer Or Paid Delinquency

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HELP
SD EForm - 0887
V1
Department of Revenue
Special Tax Division
445 East Capitol Ave
Pierre, SD 57501
To: Division of Special Tax and Licensing – Alcoholic Beverage Section
Notice of:
Delinquent Retailer
Paid Delinquency
Name of Licensee ________________________________________________________
Trade Name _____________________________________________________________
License Number __________________________________________________________
Address ________________________________________________________________
City ______________________________ State ___________ Zip _________________
Date of Invoice _________________________________________________________
Amount of Invoice of Returned Check _______________________________________
Date of Delinquency _____________________________________________________
Date Paid ____________________________________ Amount __________________
This is a true and accurate statement of the above licensee.
Wholesaler ____________________________________________________________
Address ____________________________________ City _____________________
By ___________________________________________________________________
Date__________________________________________________________________
SPT 115 (08/01)
1.
or
2.
SEND ELECTRONICALLY
PRINT FOR MAILING
EXIT
CLEAR FORM

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