Alcohol Licensee Delinquent Notices From Wholesalers

Notice of

Delinquent Retailer

Paid Delinquency

Name of Licensee

Business Name

License Number(s)

Phone Number

Date of Invoice

Amount of Invoice OR Returned Check

Date of Delinquency

Date Paid

Amount Paid

Wholesaler

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.

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First Name

Last Name

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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

Additional Email 2

Additional Email 3

Additional Email 4