Form Ab-123 - Distilled Spirits / Wine Permit Application
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4DEPARTMENT USE ONLY
Permit Number
AB-123: DISTILLED SPIRITS / WINE
PERMIT APPLICATION
Period Covered
Date of Issuance
Read instructions before completing.
Section A
All applicants complete this section
Legal Name (corporation, limited liability company, partnership, or individual)
Federal Employer ID Number
Social Security Number
(required if sole
proprietorship
or individual)
Business Name (DBA) (if different than Legal Name)
Telephone Number
Business Telephone Number
(
)
(
)
Business Address (Do not use PO Box)
City or Post Office
State
Zip Code
Mailing Address (if different than Business Address)
City or Post Office
State
Zip Code
Business Located In:
City
In the Wisconsin county of:
(check one and indicate county)
Village of:
Town
A separate permit is required for each location from which any distilled spirits or wine is sold or shipped into Wisconsin, including the
location from which invoices are issued for such sales or shipments.
Business Tax
Governing
1. Type of permit (check one)
Supplemental Fee *
Registration Fee
Statute
Public warehouse alcohol beverages . . . . . . . . . . . . . . . . . . . . . .
$200
$20
125.19
Wine direct shipper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$200
$20
125.535
Out-of-state shipper of liquor . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$500
$20
125.58
Indicate type of product being shipped:
distilled spirits
wine
cider
all
Industrial alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
-0-
$20
125.62
Industrial wine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
-0-
$20
125.63
Industrial fermented malt beverage . . . . . . . . . . . . . . . . . . . . . . .
-0-
$20
125.275
Medicinal alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
-0-
-0-
125.61
Sacramental wine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
-0-
-0-
125.56
2. Organization (check one)
If Governmental Unit, check appropriate box
Sole Proprietor
Federal
County
Partnership
Wisconsin State
Local
Wisconsin Corporation – Enter date incorporated:
Limited Liability Company – Enter date registered with the
Out-of-State Corporation – Are you registered to do business
Department of Financial Institutions:
in Wisconsin?
YES
NO
For federal income tax purposes, will the LLC be taxed as a:
Other – Describe:
Partnership
Corporation
Single member LLC dis-
regarded as a separate
entity
3. Have you as a sole proprietor, partner(s), limited liability company member(s), or corporate officer(s):
(a) Held, or now hold, a permit or certificate issued by the Wisconsin Department of Revenue?
Yes
No
If Yes, indicate: Type of permit or certificate
Permit or certificate number
Location for which it was issued
(b) Been convicted of violating federal or state laws or local ordinances other than traffic violations?
Yes
No
If Yes, check type:
Federal
State
Local Ordinances
Indicate details of the violation, including nature of violation, date, place, court, and disposition.
(c)
If you have been convicted of a felony, describe the nature of the felony. If pardoned, give date and place of the pardon and
attach a copy to the application.
Complete reverse side where applicable and sign at bottom.
AB-123 (R. 11-13)
Wisconsin Department of Revenue
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Parent category: Financial