Form Rl-57 - Dumping Certificate For Illinois Tax-Free Alcoholic Liquors - 1999

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Illinois Department of Revenue
Illinois Department of Revenue
Illinois Department of Revenue
Illinois Department of Revenue
Illinois Department of Revenue
RL-57
Dumping Certificate for Illinois Tax-Free Alcoholic Liquors
Do not write above this line.
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Two copies of this certificate must be completed. The white copy is
retained by the Illinois Department of Revenue. The yellow copy is
given to the owner identified in Step 1.
Step 1: Identify the owner of the dumped alcoholic liquors
Owner’s name __________________________________________
License number _________________________________________
Manufacturer or importing distributor
Address _______________________________________________
Date alcoholic liquors were dumped __ __/__ __/__ __ __ __
Number and street
Month
Day
Year
_______________________________________________________
City
State
ZIP
Step 2: Detail the type and amount of alcoholic liquors dumped
Equivalent in wine gallons
No. of containers
Container
Cider 0.5% to 7%
Alcoholic liquor
Alcoholic liquor
Alcoholic liquor
( e.g., bottles, cases)
size
or Beer
14% or less
> 14% and < 20%
20% or more
__________________ ________________
__________________ __________________ __________________ _________________
__________________ ________________
__________________ __________________ __________________ _________________
__________________ ________________
__________________ __________________ __________________ _________________
__________________ ________________
__________________ __________________ __________________ _________________
__________________ ________________
__________________ __________________ __________________ _________________
__________________ ________________
__________________ __________________ __________________ _________________
__________________ ________________
__________________ __________________ __________________ _________________
__________________ ________________
__________________ __________________ __________________ _________________
__________________ ________________
__________________ __________________ __________________ _________________
Total
Total
Total
Total
Total number of wine gallons
number of wine gallons
number of wine gallons
number of wine gallons
number of wine gallons
__________________ __________________ __________________ _________________
Step 3: Complete the affidavit
I, an authorized employee of the Illinois Department of Revenue,
Subscribed and sworn before me on __ __/__ __/__ __ __ __.
Month
Day
Year
state that I personally witnessed dumping of alcoholic liquors owned
by the taxpayer identified in Step 1 on the date stated in Step 1. I
_______________________________________________________
Signature of notary public
also state that the type and amount of alcoholic liquor that was
dumped is correctly detailed in Step 2.
_______________________________________________________
Street address of notary public
_______________________________________________________
_______________________________________________________
Signature of Illinois Department of Revenue employee
City, state, ZIP
_______________________________________________________
Office address of employee
Notary seal
_______________________________________________________
City, state, ZIP
(______)________________________________________________
Telephone number
RL-57 (R-5/99) IL-492-1424

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