State Form 53227 - Tax Clearance Form Page 2
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2TO: LIQUOR PERMIT APPLICANTS
FROM: INDIANA DEPARTMENT OF REVENUE
SUBJECT: TAX CLEARANCE FORM
IC 7.1-3-21-15 (a) (3) the commission shall not issue, renew, or transfer a wholesaler, retailer, dealer, or other permit of
any type if the applicant is on the most recent tax warrant list supplied to the commission by the Department of State
Revenue.
To obtain such verification, applicants must file a completed Tax Clearance Form with the Department. Applicants must
provide all requested information. Failure to timely file a Tax Clearance form or provide all requested information may
result in delay or denial of your application.
Applicants may mail the completed Tax Clearance Form to P.O. Box 2305, Indiana Government Center North, Indianapolis, IN
46206-2305. Applicants may file the Tax Clearance Form in person at Room N-105, Indiana Government Center North.
The Department of Revenue will provide information concerning tax liabilities of applicants to the Alcohol and Tobacco
Commission (ATC). ATC will provide verification of the applicant’s tax status to the local alcoholic beverage board.
For further information, call (317) 232-5977.
THE ORIGINAL BLUE FORM MUST BE COMPLETED, SIGNED AND RETURNED FOR APPROVAL.
THIS CLEARANCE IS VALID FOR THIRTY (30) DAYS ONLY.
FOR DEPARTMENT USE ONLY
A/R
RST
WTH
FAB
CIT
IND
COR
NFP
EMPLOYEE
DATE
SUPERVISOR
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