Sd Eform-0876 V1 - Report Of Alcohol Beverage Violation And Notice Of Conviction
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SD EForm - 0876
V1
STATE OF SOUTH DAKOTA
DEPARTMENT OF REVENUE
REPORT OF ALCOHOL BEVERAGE VIOLATION
AND
NOTICE OF CONVICTION
Date of Conviction
City
County
Name of Person Convicted
Address
City
Zip Code
SDCL Section Violated
BUSINESS INFORMATION
Name of Business Where Violation Occurred
Date of Offense
Address of Business Where Violation Occurred
City
Zip Code
Dated this ____________ day of _________________________, 20_____________
(Seal) ___________________________________________________________________
Signature of Clerk of Court or Authorized Representative
Please Mail along with a Certified Copy of the Judgment or Sentence To:
Department of Revenue
Special Tax Division
445 East Capitol Avenue
Pierre, SD 57501
1.
PRINT FOR MAILING
CLEAR FORM
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