Form Bt-100 - Application For Permission To Import Alcoholic Beverages From Within The United States For Personal Consumption

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FORM BT-100
STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
EXCISE/PUBLIC SERVICES SUBDIVISION
25 SIGOURNEY STREET
HARTFORD CT 06106-5032
APPLICATION FOR PERMISSION TO
IMPORT ALCOHOLIC BEVERAGES
Rev. 07/00
FROM WITHIN THE UNITED STATES
FOR PERSONAL CONSUMPTION
You must complete and file this application, together with Form S&BT, Payment of Taxes Due on the Importation of Alcoholic
Beverages , with the Department of Revenue Services at the above address. Only upon your receipt of the approved application from
the Department are you permitted to import the below referenced alcoholic beverages.
This section to be completed by the Applicant
Name of Applicant: ______________________________________________ Social Security Number: ________________________
(
)
Telephone Number: _______________________
Address (number and street, city, state, and ZIP Code): _____________________________________________________________
Name and address of person from whom alcoholic beverages were or will be purchased:
__________________________________________________________________________________________________________
This application pertains to the importation from outside Connecticut but within the territorial limits of the United States, for my own
personal consumption, of _____________________________ (not to exceed 5) gallons of alcoholic beverages, during the sixty day
period, beginning _______________________________, _________ and ending ______________________________, _________, .
Date of last application (if none, so indicate) ____________________________________
DECLARATION
I declare under the penalty of false statement that I have examined this application, FORM BT-100, and, to the best of my knowledge and
belief, it is true, complete, and correct. (The penalty for false statement is imprisonment not to exceed one year or a fine not to exceed two
thousand dollars, or both.)
________________________________________
_____________________________
Signature of Applicant
Date
I
f you need information or assistance, call the Excise/Public Services Taxes Subdivision at 860-541-3225, Monday through Friday
between the hours of 8:00 a.m. and 5:00 p.m.
This section to be completed by the Department of Revenue Services
VALIDATED ENDORSEMENT ON THIS SECTION, TOGETHER WITH AN ENDORSED FORM S&BT, IS YOUR PERMIT TO IMPORT THE
ABOVE-REFERENCED ALCOHOLIC BEVERAGES.
Date of Receipt ____________________
Date Action Taken ___________________
Action taken:
____ Application approved
By: _______________________________________________________
Signature
____ Application disapproved
_______________________________________________________
Title

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