Form SFN 60421 Application for out-Of-State Winery License to Sell Direct to North Dakota Retailers - North Dakota

Form SFN60421 or the "Application For Out-of-state Winery License To Sell Direct To North Dakota Retailers" is a form issued by the North Dakota Office of State Tax Commissioner.

Download a PDF version of the Form SFN60421 down below or find it on the North Dakota Office of State Tax Commissioner Forms website.

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APPLICATION FOR OUT-OF-STATE WINERY LICENSE
TO SELL DIRECT TO NORTH DAKOTA RETAILERS
OFFICE OF NORTH DAKOTA STATE TAX COMMISSIONER
For Calendar Year
SFN 60421 (7-13)
ND License Number (renewals only)
New License
Renewal
Federal Employee Identification Number
Legal Name
Federal Basic Permit Number
DBA (if applicable)
Physical Address
City
State
ZIP Code
Mailing Address
State
ZIP Code
City
Contact Person
Telephone Number
Email Address
Change of Any Information From Previous Application
There is no fee for this permit
Do you have an ownership interest in whole or in part, or are an officer, director, agent or
employee of any other manufacturer, brewer, importer, wholesaler or retailer, or are an affiliate
thereof, whether the affiliation is corporate or by management, direction or control?
No
Yes
If yes, list each establishment and location _________________________________________________
Do you produce more than 50,000 gallons of wine annually?
Yes
No
Attach a copy of your partnership, corporation, or other ownership agreement.
Attached
Have you ever had any type of license suspended or revoked in any state?
If yes, list where and when _____________________________________________________________
No
Yes
Agreement to Electronically File
The Tax Commissioner agrees to authorize the above named company to electronically file the tax reports and schedules
as required under North Dakota Century Code chs. 5-01 and 5-03. The signature of the company affixed to this
application shall be deemed to appear on such electronically filed reports and schedules, as if actually so appearing. All
reports and schedules filed electronically pursuant to this agreement are deemed by the company to be truthful, accurate
and complete statements made under penalty of perjury, and shall be in form compatible with the Tax Commissioner's
equipment, software, and facilities. Any electronic filing not in conformity with the requirements specified herein shall be
deemed a failure to file such reports and schedules and company shall be subject to all applicable penalties prescribed by
law.
I declare under the penalties of North Dakota Century Code § 12.1-11-02, which provides for a Class A misdemeanor for
making a false statement in a governmental matter, that this application has been examined by me and to the best of my
knowledge and belief is complete, correct, and true.
Name of Owner or Authorized Officer (print or type)
Signature of Owner or Authorized Officer
Title
Date
Please send application and license fee to:
For Tax
Office of State Tax Commissioner
Department
Sales and Special Taxes Compliance Section
Use Only
600 E. Boulevard Ave. Dept. 127
Bismarck, ND 58505-0599
Phone: (701) 328-2702
APPLICATION FOR OUT-OF-STATE WINERY LICENSE
TO SELL DIRECT TO NORTH DAKOTA RETAILERS
OFFICE OF NORTH DAKOTA STATE TAX COMMISSIONER
For Calendar Year
SFN 60421 (7-13)
ND License Number (renewals only)
New License
Renewal
Federal Employee Identification Number
Legal Name
Federal Basic Permit Number
DBA (if applicable)
Physical Address
City
State
ZIP Code
Mailing Address
State
ZIP Code
City
Contact Person
Telephone Number
Email Address
Change of Any Information From Previous Application
There is no fee for this permit
Do you have an ownership interest in whole or in part, or are an officer, director, agent or
employee of any other manufacturer, brewer, importer, wholesaler or retailer, or are an affiliate
thereof, whether the affiliation is corporate or by management, direction or control?
No
Yes
If yes, list each establishment and location _________________________________________________
Do you produce more than 50,000 gallons of wine annually?
Yes
No
Attach a copy of your partnership, corporation, or other ownership agreement.
Attached
Have you ever had any type of license suspended or revoked in any state?
If yes, list where and when _____________________________________________________________
No
Yes
Agreement to Electronically File
The Tax Commissioner agrees to authorize the above named company to electronically file the tax reports and schedules
as required under North Dakota Century Code chs. 5-01 and 5-03. The signature of the company affixed to this
application shall be deemed to appear on such electronically filed reports and schedules, as if actually so appearing. All
reports and schedules filed electronically pursuant to this agreement are deemed by the company to be truthful, accurate
and complete statements made under penalty of perjury, and shall be in form compatible with the Tax Commissioner's
equipment, software, and facilities. Any electronic filing not in conformity with the requirements specified herein shall be
deemed a failure to file such reports and schedules and company shall be subject to all applicable penalties prescribed by
law.
I declare under the penalties of North Dakota Century Code § 12.1-11-02, which provides for a Class A misdemeanor for
making a false statement in a governmental matter, that this application has been examined by me and to the best of my
knowledge and belief is complete, correct, and true.
Name of Owner or Authorized Officer (print or type)
Signature of Owner or Authorized Officer
Title
Date
Please send application and license fee to:
For Tax
Office of State Tax Commissioner
Department
Sales and Special Taxes Compliance Section
Use Only
600 E. Boulevard Ave. Dept. 127
Bismarck, ND 58505-0599
Phone: (701) 328-2702

Download Form SFN 60421 Application for out-Of-State Winery License to Sell Direct to North Dakota Retailers - North Dakota

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