Form Altret - Alteration Request Form Page 3
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5Section 5 - Declaration and Affidavit
This form needs to be signed by all individuals, members or partners. In the case of a corporate licensee, it may be signed
by one shareholder or officer with authority to sign.
I/We declare under penalty of false swearing that the information provided on this form and its attachments is true, correct,
and complete.
__________________________________________________________________________
_____________________
Signature
Date
________________________________________________________________
_______________________________
Printed Name
Title
Mail completed form to:
Montana Department of Revenue
Liquor Control Division
PO Box 1712
Helena, MT 59624-1712
Questions?
Phone: Toll Free at 1-866-859-2254 (in Helena, 444-6900)
Fax:
(406) 444-0722
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