Form 0405-403.1 - Alcoholic Beverage Excise Tax License Application

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403.1
Alcoholic Beverage Excise Tax
License Application
Federal ID
SSN
EIN
License number
Brewery
Winery
Distillery
Is this a renewal?
Yes
No
Business name
Taxpayer name
License year
Mailing address
Physical location where this license is applicable
City
State
ZIP+4
Contact telephone
Business Telephone
Contact person
Contact email
Contact fax
Business owner’s name
Contact telephone
Business physical address
City
State
ZIP + 4
Name of personnel who may authorize immediate inspection of the licensed business. Use additional pages as necessary.
Estimated Maximum Monthly Tax Calculation
Estimated maximum monthly
Alcoholic beverages excise
production for license year
Excise tax
tax rates
(gallons)
Liquor
X
$12.80
=
Wine & other
X
$2.50
=
Beer, cider & malt beverages
X
$1.07
=
Beer (microbreweries)
X
$0.35
=
Total estimated maximum monthly tax
=
Your estimated maximum monthly tax liability must be secured by a surety bond or at it’s discretion, DOR may issue a permit
in lieu of a bond.
Surety Bond in the amount of $25,000. Attach the Alcoholic Beverages Surety Bond (Form 0405-405).
Permit in lieu of bond (cash, letter of credit or certificate of deposit from an Alaska Bank in an amount equal to the total estimated
maximum monthly tax indicated above). You must be doing business wholly in the state of Alaska to qualify. For new applicants,
attach a written request for permit in lieu of bond.
I declare under penalty of unsworn falsification that this application and any attachments have been examined by me and to the best of my
knowledge and belief are true, I agree to pay all alcoholic beverage excise taxes imposed by AS 43.60. I agree to file a monthly tax return.
Signature of applicant (must be an owner or corporate officer)
Printed name
Date
Pay online at
Mail to: Alaska Department of Revenue - Tax Division
Online payment receipt # ________________
550 W 7TH AVE STE 500
or make check payable to State of Alaska
ANCHORAGE AK 99501-3566
Telephone (907) 269-6620 • Fax (907) 269- 6644
dor.tax.alcohol@alaska.gov
403.1
Retain a copy for your records
0405-403.1 rev 03/10

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