Form R-5626 - Application For Authority To Ship Alcoholic Beverages Into Louisiana
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1R-5626 (7/09)
Application for Authority to Ship
Alcoholic Beverages into Louisiana
Mail to:
Taxpayer Services Division
Excise Tax Section
P. O. Box 201
Baton Rouge, LA 70821-0201
Date of Application
_______________
(mm/dd/yyyy)
PLEASE PRINT OR TYPE.
Legal Name of Business/Shipper
Trade Name of Business/Shipper
Mailing Address
Location Address
City
State
Zip
City
State
Zip
Contact Person
Title
Telephone
Fax
(
)
(
)
Federal Employer ID No.
Social Security Number
(if no FEIN)
In accordance with Louisiana Revised Statute 26:364, application is hereby made for authority to make shipments of
Beverages of Low Alcoholic Content
(contains not more than 6% by volume)
Malt Beverages of High Alcoholic Content
(contains more than 6% by volume)
Beverages of High Alcoholic Content
(contains more than 6% by volume)
to licensed and bonded wholesale dealers listed below with the complete name and location address of the business:
Wholesale Dealer
Location Address
City
ZIP
In accordance with R.S. 26:364(B), I/we hereby certify that I/we are the:
Distiller
Producer
Bottler
Owner of the commodity at the time it becomes a marketable product, or
The Exclusive Agent of one or more of the above. If an Exclusive Agent, state principal and the product being shipped
(attach a
supplement if needed) __________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
A copy of the invoiced listing the merchandise and total amount shipped to the Louisiana wholesale dealer MUST be mailed to the Department of
Revenue, Taxpayer Services Division, Excise Tax Section upon execution of the shipment.
Shipper
Authorized Signature
Title
Date
(mm/dd/yyyy)
X
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