Form Rl-4 - Application For Permit To Purchase Alcoholic Liquors Tax Free For Nonbeverage Purposes

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Illinois Department of Revenue
Application for Permit to Purchase
RL-4
Alcoholic Liquors Tax Free for Nonbeverage Purposes
Permit no.: __________
Read this information first
Date issued: ___/___/___
File this application if you have been issued a nonbeverage user’s
Liquor Control Commission and the Illinois Department of Revenue
license by the Illinois Liquor Commission and you want to purchase
under authority contained in the Liquor Control Act of 1934.
alcoholic liquors from a licensed distributor without paying the Illinois
If you have questions, call us weekdays at 217 558-7425.
Liquor Tax.
Mail your completed application to:
Your application must be made out for the exact quantity of alcoholic
CENTRAL REGISTRATION DIVISION
liquor you intend to purchase.
ILLINOIS DEPARTMENT OF REVENUE
Upon approval of your application, we will issue your RL-5, Permit to
PO BOX 19039
Purchase Alcoholic Liquors Tax Free for Nonbeverage Purposes. All
SPRINGFIELD IL 62794-9039
permits are subject to the rules and regulations issued by the Illinois
Step 1: Identify your business
Name __________________________________________________
Nonbeverage user license number ___________________________
Address: ______________________________________________
FEIN __________________________________________________
Number and street
_______________________________________________________
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: ____ cider ____ beer
____ wine ____ spirits
Quantity
without paying the 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 only if you want your RL-5 Permit sent directly to your distributor
If you want your RL-5 Permit sent to you, skip to Step 4.
Name __________________________________________________
Distributor license number ___________________________
Attention _______________________________________________
Distributor FEIN _________________________________________
Address _______________________________________________
Number and street
_______________________________________________________
City
State
ZIP
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
234511110
This form is authorized by the Liquor Control Act of 1934.
Disclosure of this information is REQUIRED. Failure to provide
information could result in denial of this application.
RL-4 (R-11/12)
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