Illinois Department of Revenue
Application for Permit to Purchase
Permit no.: __________
RL-4
Alcoholic Liquors Tax Free for Nonbeverage Purposes
Date issued:___/___/___
Read this information first
File this application if you have been issued a nonbeverage user’s
Mail your completed application to:
license and want to purchase alcoholic liquors from a manufacturer
MISCELLANEOUS TAXES DIVISION
or an importing distributor without paying the Illinois Liquor Tax.
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19039
Your application must be made out for the exact quantity of alcoholic
SPRINGFIELD IL 62794-9039
liquor you intend to purchase.
or
All permits are subject to the rules and regulations issued by the
Illinois Liquor Control Commission and the Illinois Department of
CASHIER/DEPOSIT SECTION C-300
Revenue under authority contained in the Liquor Control Act of 1934.
ILLINOIS DEPARTMENT OF REVENUE
If you have questions, call our Springfield office at 217 782-7610 or
100 WEST RANDOLPH STREET
our Chicago office at 312 814-3221.
CHICAGO IL 60601-3274
Step 1: Identify your business
Name __________________________________________________
Nonbeverage user license number ___________________________
Address _______________________________________________
Class number ___________________________________________
Number and street
_______________________________________________________
Kind of business _________________________________________
City
State
ZIP
Step 2: Complete the following statement
I, ___________________________________, state that I am the ____________________________ of the business applying for a permit
Name
Title ( e.g., president, secretary, partner, sole owner)
to purchase ____________ wine gallons of alcoholic liquor of the following classification _________________________ without paying the
Quantity
( e.g. , beer, wine)
Illinois Liquor Tax. I have complete knowledge of the use to which the alcoholic liquor will be put, and I am authorized to make these
statements for the purpose of receiving permission to purchase alcoholic liquors from a manufacturer or an importing distributor who is not
liable for paying the tax imposed by the Liquor Control Act of 1934 with respect to this sale. I also certify that the alcoholic liquors that will be
purchased with this permit are exclusively for use in _____________________________________________________________________;
Details of usage
that when they are used, they will be rendered unfit for beverage purposes; and that none of the alcoholic liquors will be sold or otherwise
disposed of in the same condition as received.
Step 3: Complete the following table
For each class of alcoholic liquor you purchased during the past six months, write the number of wine gallons and purpose for which used.
Cider 0.5% to 7%
Alcoholic liquor
Alcoholic liquor
Alcoholic liquor
Month
or Beer
14% or less
> 14% and < 20%
20% or more
Purpose for which used
_________
_________________
_________________
_________________
_________________
________________________
_________
_________________
_________________
_________________
_________________
________________________
_________
_________________
_________________
_________________
_________________
________________________
_________
_________________
_________________
_________________
_________________
________________________
_________
_________________
_________________
_________________
_________________
________________________
_________
_________________
_________________
_________________
_________________
________________________
Total
_________________
_________________
_________________
_________________
Step 4: Sign below
Under penalties of perjury, I state that I have examined this application and, to the best of my knowledge, it is true, correct, and complete.
______________________________________________________
_________________________________________
____________
Signature
Title
Date
This form is authorized by the Liquor Control Act of 1934. Disclosure of this information is REQUIRED. Failure to provide
RL-4 (R-5/99)
information could result in denial of this application. This form has been approved by the Forms Management Center.
IL-492-1487