Form Bt-21 - Alcoholic Beverages Tax Exemption Certificate - Department Of Revenue Services
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2STATE OF CONNECTICUT
Form BT-21
DEPARTMENT OF REVENUE SERVICES
Excise/Public Services Taxes Subdivision
Alcoholic Beverages Tax
25 Sigourney Street
Hartford CT 06106-5032
Exemption Certificate
Rev. 09/01
A distributor must use this certificate to document sales to instrumentalities of the federal government. This certificate must be completed before the distributor can
release alcoholic beverages to the instrumentalities.
Name of Instrumentality of the Federal Government
Name of Distributor
Address
Address
Town or City
Town or City
Invoice
Distilled
Still
Sparkling
Date
Number
Quantity
Item
Size
Barrels
Gallons
Liquor
Wine
Wine
(wine gallon)
(wine gallon)
(wine gallon)
This is to certify that the alcoholic beverages listed above have been delivered to the authorized
This is to certify that the alcoholic beverages listed above are to be used only by the instrumentality of
instrumentality of the federal government at the address indicated above. I declare under penalty of
the federal government indicated above. I declare under penalty of law that I have examined this return
law that I have examined this return and, to the best of my knowledge and belief, it is true, complete,
and, to the best of my knowledge and belief, it is true, complete, and correct. I understand that the
and correct. I understand that the penalty for willfully delivering a false return to DRS is a fine of not
penalty for willfully delivering a false return to DRS is a fine of not more than $5,000, or imprisonment for
more than $5,000, or imprisonment for not more than five years, or both. The declaration of a paid
not more than five years, or both. The declaration of a paid preparer other than the taxpayer is based
preparer other than the taxpayer is based on all information of which the preparer has any knowledge.
on all information of which the preparer has any knowledge.
Name of Distributor
Name of Instrumentality of the Federal Government
By
Date
By
Date
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