Section 1 of 1 in this document
Alcohol Licensee Delinquent Notices From Wholesalers
Notice of
Delinquent Retailer
Paid Delinquency
Name of Licensee
*
Business Name
*
License Number(s)
*
Full Address
Street Address
*
City
*
State
*
Zip
*
Phone Number
Email
*
Date of Invoice
*
Amount of Invoice OR Returned Check
Date of Delinquency
Date Paid
Amount Paid
Wholesaler
*
Wholesaler's Address
Street Address
City
State
Zip
Acknowledgement Required
I certify that the written notice of delinquency required under ARSD 64:75:04:04 has been provided to the delinquent retailer and a copy of the notice of delinquency is attached.
Please Upload the Written Notice of Delinquency
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First Name
Last Name
Email
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By electronically signing this document, I certify that I am authorized to sign and that the above information is true and correct.
Additional Email
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