Form Ab-204 - Limited Manufacturer Permit Applicaiton
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2AB-204: Limited Manufacturer
DEPARTMENT USE ONLY
Permit Number
Permit Applicaiton
Period Covered
Date of Issuance
Read instructions before completing application.
Legal Name (Corporation, Limited Liability Company, Partnership, or Sole Proprietorship)
Federal Employer ID Number
Social Security Number
–
Business Name (DBA) (if different than Legal Name)
Telephone No.
(
)
Business Address (permit location)
Business located in
Business Telephone
(
)
City
Village
Town
City or Post Office
State
Zip Code
County
of:
City or Post Office
State
Zip Code
Mailing Address (if different than Business Address)
FEE
GOVERNING STATUTE
$20.00
Business Tax Registration
Sec. 125.52, Wis. Stats.
1. Premises Description: Describe building or buildings where alcohol will be manufactured and stored.
2. Organization (check one)
Sole Proprietor
Partnership: Indicate Type
General
Limited
Limited Liability Partnership (LLP)
Wisconsin Corporation – Enter date incorporated:
Out-of-State Corporation – Are you registered to do business in Wisconsin?
Yes
No
Limited Liability Company – Enter date registered with Department of Financial Institutions:
Taxed as a:
Single member LLC disregarded as a separate entity
Partnership
Corporation
Nonprofit organization
Governmental Unit
Federal
Wisconsin State
County
Local
Tribal
Other – Describe:
3. Federal permit issued.
Type
Number
Date
4. Have you taken over the business of another permittee?
If Yes, indicate name and address of predecessor.
Yes
No
Name
Address
5. Profession or business.
6. Purpose for which alcohol will be used. (Describe in detail)
7. Estimated amount in gallons to be manufactured monthly.
Declaration (All applicants complete this section)
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
Title
Date
Signature
Title
Date
NOTE: If applicant is a corporation, the president and the secretary must sign. If applicant is a partnership, two partners must sign. If a limited liability
company, two members must sign unless the limited liability company only has one member.
AB-204 (R. 12-13)
Wisconsin Department of Revenue
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Parent category: Financial