Form Bt-101 - Alcoholic Beverage Tax printable pdf download

Department of Revenue Services

Form BT-101

State of Connecticut

Excise Taxes Unit

Alcoholic Beverage Tax

25 Sigourney Street

Hartford CT 06102-5031

Application for Permission to Import Into Connecticut Alcoholic Beverages

(Rev. 02/05)

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 (DRS) at the above address. Only upon your receipt from the Department of

the approved application are you permitted to import the alcoholic beverages referenced below. For more information on the

importation of alcoholic beverages into Connecticut, see Informational Publication 2000 (15), Bringing or Importing Alcoholic

Beverages Into Connecticut.

This section to be completed by the applicant

Name of Applicant: ______________________________________________ Social Security Number: _______________________

Date of Birth: ___________________________________________________ Date Alcohol Received: ________________________

Address (number and street, city, state, and ZIP Code): _____________________________________________________________

(

)

Telephone Number: _____________________________________________

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 penalty of law that I have examined this return (including any accompanying schedules and statements) and, to the best of

my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return to DRS is a fine of not more than

$5,000, or imprisonment for not more than five years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of which

the preparer has any knowledge.

Taxpayer Signature

Title

Date

Print Taxpayer Name

Telephone Number

Taxpayer SSN

Paid Preparer Signature

Preparer’s Address

Preparer’s SSN or PTIN

f you need information or assistance, please call the Excise Taxes Unit at 860-541-3224, Monday through Friday between the hours

of 8:00 a.m. and 5:00 p.m.