Form Ab-157 - Permittees Statement Of Brand Franchise And Sales Area Designation - Wisconsin Department Of Revenue

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PERMITTEES STATEMENT OF BRAND
Wisconsin Department of Revenue
Excise Tax Section 6-107
FRANCHISE AND SALES AREA DESIGNATION
PO Box 8900
Madison, WI 53708-8900
(608) 261-6435
Fax (608) 261-7049
Permit Number
Legal Name
Street Address
City
State
Zip Code
PERMITTEES STATEMENT OF BRAND FRANCHISE AND SALES AREA DESIGNATION
No Wisconsin liquor wholesaler or rectifier may sell any distilled spirits and wine in Wisconsin until a written statement is filed with the
department indicating that (1) the permittee is a distributor of a particular brand of liquor in Wisconsin, and (2) sales of the brand by the
permittee and anyone purchasing from the permittee will be limited to the franchise sales area specified. The permittee shall notify the
department of any change in the area within seven days of the effective date of the change.
Attach a list if more space is needed and check the box indicating that a list is attached.
Manufacturer
Franchise Sales Area
(Name, City, State)
Brand or Brand Name
(Counties or portion of counties)
SIGNATURE
(All applicants must sign)
I declare under penalties of the law that I have examined this information and to the best of my knowledge it is true, correct, and complete.
Signature (do not print or type)
Title
Date
Signature (do not print or type)
Title
Date
If applicant is a corporation, the president and the secretary must sign. If applicant is a partnership, two partners must sign. If applicant is a limited liability
company, two members must sign unless the limited liability company only has one member.
AB-157 (R. 11-11)

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