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FORM BT-101

STATE OF CONNECTICUT

DEPARTMENT OF REVENUE SERVICES

EXCISE/PUBLIC SERVICES SUBDIVISION

25 SIGOURNEY STREET

APPLICATION FOR PERMISSION TO

HARTFORD CT 06106-5032

IMPORT ALCOHOLIC BEVERAGES

Rev. 07/00

FROM OUTSIDE 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 from the Department of the

approved application 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): ______________________________________________________________

Check the applicable box

This application pertains to the importation, from outside the territorial limits of the United States, for my own personal

consumption, of ________________________(not to exceed 5) gallons of alcoholic beverages, whether or not purchased by

me, during the 365 day period beginning _______________________________, __________ and ending

______________________________, _________, .

Date of last application (if none, so indicate): ___________________________

This application pertains to the importation, from outside the territorial limits of the United States, for my own personal

consumption, of;

____ (not to exceed 100, of which no more than 20 gallons are of the same brand) gallons of wine; and

____ (not to exceed 20, of which no more than 2 gallons are of the same brand) gallons of spirits;

and coincides with the termination of my foreign residency of at least 6 months, and is in connection with the return of my

personal and household goods.

Former Foreign Residence Address: ______________________________________________________________

Date of Termination of Foreign Residency: _________________________________________________________

Duration of Foreign Residency: ____________________________ years _________________________ months

DECLARATION

I declare under the penalty of false statement that I have examined this application, FORM BT-101, 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

f you need information or assistance, please 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 ____________________

Signature

Action taken:

____ Application approved

By: _______________________________________________________

Title

____ Application disapproved

_______________________________________________________

Form Bt-101 - Application For Permission To Import Alcoholic Beverages From Outside The United States For Personal Consumption

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