Form R-8695 - Application For Authority To Make Direct Shipments Of Wines To Louisiana Consumers

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R-8695 (6/13)
Mail To:
Louisiana Department of Revenue
Special Programs Division
Application for Authority to Make
Excise Taxes Section
Direct Shipments of Wines to
P.O. Box 201
Louisiana Consumers
Baton Rouge, LA 70821-0201
Telephone: 225.219.7656 • TDD : 225.219.2114
Excise Inquiry Box: excise.inquiries@la.gov
Date of Application
(mm/dd/yyyy)
Filing Period
6/30/2014
July 1, 2013 through June 30, 2014
PLEASE PRINT OR TYPE.
LA Revenue Account Number
Federal Employer ID No.
Legal Name of Business
Trade Name of Business
Mailing Address
Location Address
City
State
ZIP
City
State
ZIP
Contact Person
Title
Telephone
Fax
ONLY ONE
Check
box that best describes your business:
Annual Fee Due
150.00
1.
Wine producer domiciled inside or outside of Louisiana (Annual fee of $150).
1.
$
150.00
Manufacturer domiciled outside of Louisiana (Annual fee of $150).
2.
2.
$
1,500.00
3.
Retailer domiciled outside of Louisiana (Annual fee of $1,500).
3.
$
4.
Amount Due. (Enter the amount from either Line 1, 2, or 3 here.)
Make payment to the Louisiana Department of Revenue.
4.
$
NOTE: You must have been issued the equivalent of a wine producer, manufacturer, or retailer license by your home state. A
copy of that license must accompany this application.
Declaration
I hereby reapply for authorization to make direct shipments of sparkling and/or still wines to consumers in Louisiana. I agree to pay all excise and sales and use
taxes assessed by the State of Louisiana. I agree to file a monthly return listing all direct shipments to Louisiana consumers and remitting the applicable taxes
by company check or electronic funds transfer. I further agree to observe all requirements concerning direct shipments, as specified on the back of this form.
I acknowledge that Louisiana law provides for a civil penalty of $25,000 for violation of those requirements. I am not a party to any direct or indirect agreement
with a Louisiana registered wholesale dealer as defined by item number one on the reverse side of this form. Payment of the annual fee is included with this
renewal application.
Signature
Date
(mm/dd/yyyy)
X
8705

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