Tabc Form L 103 PDF Details

The TABC L-103 form serves as a comprehensive application for entities outside of Texas seeking authorization to engage in the sale, brewing, or manufacturing of alcoholic beverages within the state. Known as the Application for Nonresident Seller’s Permit, Nonresident Brewer’s Permit, and Nonresident Manufacturer’s License, this document captures a wide array of information critical for the regulatory oversight and operational legality of such entities in Texas. It demands meticulous details including, but not limited to, the type of permit being applied for, business trade name, physical and mailing addresses, and contact information. Additionally, it requires personal details of individuals and key stakeholders involved in the business, highlighting the emphasis on thorough vetting processes. The form also probes into the applicant’s compliance with industry regulations, such as maintaining clear boundaries between manufacture, wholesale, and retail sectors of the industry, and ensures that applicants are the primary source of supply for the brands they wish to sell. Further scrutiny is applied regarding the actual manufacturing locations and the logistical details of transporting the product into Texas, underscoring the state’s stringent stance on tracking and quality control. Lastly, a section for acknowledgment warns about the legal implications of falsifying information on the application, underlining the seriousness with which the Texas Alcoholic Beverage Commission (TABC) takes the permitting process. This multifaceted document, thus, lays the foundation for regulating nonresident entities’ operations in the Texas alcoholic beverage market, ensuring compliance, and safeguarding the interests of the state and its residents.

QuestionAnswer
Form NameTabc Form L 103
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesL 103 tabc application form

Form Preview Example

APPLICATION FOR NONRESIDENT SELLER’S PERMIT, NONRESIDENT BREWER’S PERMIT AND NONRESIDENT

MANUFACTURER’S LICENSE

FIRST READ ALL INSTRUCTIONS

TYPE OR PRINT IN INK

 

FORM L-103 (11/2011)

TABC USE ONLY

ISSUE DATE

S

U

BS

1A. APPLICATION FILED FOR:

S NONRESIDENT SELLER’S PERMIT U NONRESIDENT BREWER’S PERMIT

BS NONRESIDENT MANUFACTURER’S LICENSE

 

 

 

 

 

 

FEE

 

SURCHARGE

 

LATE FEE (RENEWAL ONLY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Registry No.

FOR ALL APPLICANTS

FOR INDIVIDUAL

ONLY

FOR ALL APPLICANTS

TABC USE

B. APPLICATION FILED FOR:

Original

Renewal Change

Change of:

C. If renewal or change, enter license/permit no(s).:

S-

 

 

U-

 

 

BS-

 

2. APPLICATION IS FILED BY:

 

 

 

 

 

 

Individual

Corporation

Limited Liability Company

Other:

 

 

Partnership

Limited Partnership

Limited Liability Partnership

3.Trade Name of Business

4.Address or Location

 

City

 

 

County

State

Zip Code (9 digits)

 

 

 

 

 

 

-

 

 

 

 

 

 

5.

Mailing Address

 

 

City/Foreign Country State

Zip Code (9 digits)

 

 

 

 

 

 

-

 

 

 

 

 

6.

Area Code + Business

Area Code + Alternate

E-mail Address (optional)

 

 

Telephone Number

Telephone Number

 

 

 

( )

-

( )

-

 

 

FOR INDIVIDUAL

7. Social Security Number

Issuing State and Driver’s License Number

Date of Birth (mm/dd/yyyy)

-

-

 

/

/

 

 

 

 

 

Full Legal Name (Last, First, Middle)

 

 

 

 

 

 

 

 

Residential Address

City

State

Zip Code ( 9 Digits )

 

 

 

 

 

-

ALL APPLICANTS

8.Give name, address, and phone number of appointed agent, resident of Texas, certified by applicant to the Secretary of State at Austin, Texas, as the person upon whom notice of a hearing may be served concerning matters, proceedings, hearings and causes involving the refusal, cancellation or suspension of a permit or license issued by this commission. Name shown here must be the same as that shown on Form L-20.2.

Name:

Address:

 

 

 

Phone Number: ( )

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INITIAL APPLICATION

 

 

 

 

 

 

 

 

ADDITIONAL

 

 

 

 

 

 

PROCESSOR REVIEW

 

 

 

 

 

 

 

 

 

 

 

YES - NO

 

 

 

 

 

 

YES - NO

 

 

 

 

 

/

/

 

 

 

 

INCOMPLETE

 

 

 

 

 

 

CORRESPONDENCE

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE

 

 

 

YES - NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

# OF PAGES

 

 

 

 

 

CROSS CHECK DATE

 

 

 

 

 

 

CROSS CHECKED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WRITTEN

/

/

END PROCESS

/

/

PROCESSOR

PROCESSOR

YES

-

NO

PROCESS DATE

DATE

I.D.

ERROR

 

 

 

 

 

 

 

Page 1 of 4

FOR ALL OFFICER(S), PARTNER(S), DIRECTOR(S), MANAGER(S), STOCKHOLDER(S) AND MEMBER(S).

P A R T N E R S H I P S / C O R P O R A T I O N S

TRADE NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM L-106-PC (8/2005)

1A. Indicate type of ownership and complete the information below:

 

 

 

 

 

 

 

 

 

 

 

 

Corporation

Limited Liability Company

Partnership

Limited Partnership

Limited Liability Partnership

B. Federal Employer’s I.D. No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Entity Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D. Charter No.:

 

 

 

 

Date Approved:

 

/

 

/

 

 

 

State:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E. Number and class of shares, memberships or units issued:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. COMPLETE THE FOLLOWING PER INSTRUCTIONS:

 

 

 

 

 

 

 

 

 

 

 

Social Security Number

Issuing State and Driver’s License Number

 

Date of Birth (mm/dd/yyyy)

 

 

Class & No. Shares Held

-

-

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

or % Memberships

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or % Interest

Full Legal Name (Last, First Middle)

Officer

Partner

Director/

Stockholder/

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manager

Member

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residential Address

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code (9 digits)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

Social Security Number

Issuing State and Driver’s License Number

 

Date of Birth (mm/dd/yyyy)

 

 

Class & No. Shares Held

-

-

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

or % Memberships

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or % Interest

Full Legal Name (Last, First Middle)

Officer

Partner

Director/

Stockholder/

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manager

Member

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residential Address

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code (9 digits)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

Social Security Number

Issuing State and Driver’s License Number

 

Date of Birth (mm/dd/yyyy)

 

 

Class & No. Shares Held

-

-

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

or % Memberships

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or % Interest

Full Legal Name (Last, First Middle)

Officer

Partner

Director/

Stockholder/

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manager

Member

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residential Address

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code (9 digits)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

Social Security Number

Issuing State and Driver’s License Number

 

Date of Birth (mm/dd/yyyy)

 

 

Class & No. Shares Held

-

-

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

or % Memberships

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or % Interest

Full Legal Name (Last, First Middle)

Officer

Partner

Director/

Stockholder/

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manager

Member

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residential Address

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code (9 digits)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

Social Security Number

Issuing State and Driver’s License Number

 

Date of Birth (mm/dd/yyyy)

 

 

Class & No. Shares Held

-

-

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

or % Memberships

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or % Interest

Full Legal Name (Last, First Middle)

Officer

Partner

Director/

Stockholder/

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manager

Member

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residential Address

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code (9 digits)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

Social Security Number

Issuing State and Driver’s License Number

 

Date of Birth (mm/dd/yyyy)

 

 

Class & No. Shares Held

-

-

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

or % Memberships

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or % Interest

Full Legal Name (Last, First Middle)

Officer

Partner

Director/

Stockholder/

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manager

Member

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residential Address

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code (9 digits)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(IF YOU NEED ADDITIONAL SPACE FOR MORE NAMES, USE ADDITIONAL COPIES OF THIS PAGE)

Page 2 of 4

A L L A P P L I C A N T S

FOR ALL APPLICANTS

TRADE NAME:

FORM L-103 (11/2011)

ALL APPLICANTS

9.The applicant or permit and license holder may have an interest, directly or indirectly in only one level of the alcoholic beverage industry; i.e. manufacture, wholesale or retail. You or your agent, servant or employee may not:

1.be employed in any capacity at different levels,

2.rent or lease property or equipment from or to an entity operating at another level,

3.secure credit or a loan in any form for an entity at another level,

4.control in any fashion the interests of a permittee or licensee at a different level.

A. Are you or anyone indicated in questions 7 on L-103 or 2 on L-106-PC in violation of the above

requirements?

9A. YES NO

If “YES,” explain below: (If more space is needed, attach a page.)

 

 

 

 

 

 

 

 

 

FOR NONRESIDENT SELLER’S PERMIT

FOR NONRESIDENT SELLER’S PERMIT

NOTE: Section 37.10(a) and (b) provides: “ No holder of a nonresident seller’s permit may solicit, accept, or fill an order for distilled spirits or wine from a holder of any type of wholesaler’s permit unless the nonresident seller is the primary source for the brand of distilled spirits or wine that is ordered. In this section, “primary American source of supply” means the distiller, the producer, the owner of the commodity at the time it becomes a marketable product, the bottler, or the exclusive agent of any of those. To be the “primary American source of supply” the nonresident seller must be the first source, that is the manufacturer or the source closest to the manufacturer, in the channel of commerce from whom the product can be secured by American wholesalers.”

10.Is the applicant “the primary American source of supply” for any brands of distilled spirits or

wine within the meaning of Section 37.10(a) and (b) of the Texas Alcoholic Beverage Code?

10.

YES NO

If “YES,” specify the manufacturer and brands of distilled spirits and/or wine. (If more space is needed, attach a page.)

 

 

FOR NONRESIDENT MANUFACTURER’S LICENSE

 

 

 

 

 

 

 

 

 

 

NONRESIDENT

BREWER’S PERMIT

 

 

 

 

FOR NONRESIDENT MANUFACTURER’S LICENSE

NOTE: IF APPLYING FOR A NONRESIDENT BREWER’S PERMIT AND/OR NONRESIDENT MANUFACTURER’S LICENSE, EACH LOCATION WHERE PRODUCT IS MANUFACTURED AND SHIPPED INTO THIS STATE MUST APPLY FOR AND OBTAIN A PERMIT OR LICENSE.

11A. Will the applicant actually engage in the business of brewing and packaging beer within a three

 

 

 

year period covered by its original license and two successive renewals thereof in such

 

 

 

quantities as will make its operation that of a bona fide brewing manufacturer?

11A.

YES

NO

B. Is applicant the actual manufacturer of the beer to be imported into the State of Texas?

B.

YES

NO

C. Is location in question 4 the actual manufacturing location of the product being shipped into

 

 

 

Texas?

C.

YES

NO

If answer is “NO,” application cannot be approved.

 

 

 

D. Will the applicant transport beer into Texas in vehicles owned or leased by applicant?

D.

YES

NO

If answer is “YES,” refer to #5 of the instructions shown on page 4 for necessary bond

 

 

 

requirement.

 

 

 

FOR NONRESIDENT BREWER’S PERMIT

 

 

 

12.Is location in question 4 the actual manufacturing location of the product being shipped into

Texas?

12.

YES NO

 

 

If answer is “NO,” application cannot be approved.

 

 

Page 3 of 4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A C K N O W L E D G M E N T

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRADE NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM L-103 (11/2011)

 

 

 

 

 

 

 

WARNING: Section 101.69 of the Texas Alcoholic Beverage Code is as follows: “…a person who makes a false statement

 

 

 

 

 

 

 

or false representation in an application for a permit or license or in a statement, report, or other instrument to be filed

 

 

 

 

 

 

 

with the Commission and required to be sworn commits an offense punishable by imprisonment in the penitentiary for

 

 

 

 

 

 

 

not less than 2 nor more than 10 years.”

 

 

 

 

 

 

 

 

 

 

 

 

ACKNOWLEDGMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACKNOWLEDGMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

sworn by me, states under oath that he or she read the said application

 

 

If Applicant is:

 

 

Officer or Manager

 

 

 

 

 

 

 

 

 

 

Who Must Sign:

 

PRINT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual

 

 

Individual Owner

 

NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME MUST APPEAR AS NAME SHOWN IN QUESTION 7 ON L-103 OR 2 ON L-106-PC.

 

 

 

 

 

 

 

Partnership

 

 

Partner

 

SIGN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HERE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corporation

 

 

Officer

 

 

SIGNATURE MUST APPEAR AS NAME SHOWN IN QUESTION 7 ON L-103 OR 2 ON L-106-PC.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Before me, the undersigned authority, on this

 

 

day

 

 

 

 

 

 

 

Limited Partnership

 

 

General Partner

 

 

 

 

 

 

 

 

 

 

 

 

Limited Liability

 

 

 

 

 

 

 

of

 

 

, 20

 

 

the person whose name

 

 

 

 

 

 

 

 

 

General Partner

 

 

 

 

 

 

 

 

 

 

Partnership

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

is signed to the foregoing

application

personally

appeared and, duly

 

 

 

 

 

 

 

Limited Liability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Company

 

 

 

 

 

 

 

and that all the facts therein set forth are true and correct.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HERE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(S E A L)

 

 

 

 

 

 

 

 

 

 

 

 

NOTARY PUBLIC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Beginning September 1, 2009 the license covered under this form will be issued for a two-year period. You MUST renew for the entire

 

 

 

 

 

 

 

two-year period. The total amount of fees plus surcharges to cover the two-year period MUST be paid at the time of renewal. Fees

 

 

 

 

 

 

 

may NOT be prorated or refunded.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Prepare the application in duplicate. Mail the original application to the Texas Alcoholic Beverage Commission, P.O. Box 13127,

 

 

 

 

 

 

 

Austin, Texas 78711 with the correct license/permit fees, surcharges and bond (if required). Keep duplicate for your files. Fees and

 

 

 

 

 

 

 

surcharges must be paid with Cashier’s Check, Money Order, or Firm Check from a corporate permittee made payable to the

 

 

 

 

 

 

 

Comptroller of Public Accounts. We will not accept personal checks.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Class of Permit or License

 

 

Annual State Fee

 

*Surcharge

 

 

 

Total Due

 

 

 

 

INSTRUCTIONS

 

 

 

 

 

Effective 9/01/11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nonresident Seller’s Permit

 

$300.00

 

$376.00

 

 

 

$676.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nonresident Brewer’s Permit

 

$3,000.00

 

$376.00

 

 

 

$3,376.00

 

 

 

 

 

 

 

 

 

 

Nonresident Manufacturer’s License

 

$1,500.00

 

$576.00

 

 

 

$2,076.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*SURCHARGE SUBJECT TO ANNUAL CHANGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. *Surcharges are subject to annual change. The surcharges assessed each year are determined by the Texas Alcoholic Beverage

 

 

 

 

 

 

 

Commission and not by the Legislature. The Legislature determines the total dollar amount to be raised in agency revenue. The

 

 

 

 

 

 

 

revenue is comprised of fees, which are set by the Legislature, and the surcharges which are determined by the agency.

 

 

 

 

 

 

 

4. A Power of Attorney designating Service Agent on Form L-20.2 must be mailed directly to the Secretary of State of Texas. Only a

 

 

 

 

 

 

 

Texas resident, 18 years or older, may be appointed as Service Agent. The power of attorney designating Service Agent should

 

 

 

 

 

 

 

indicate the individual named in question 8 on L-103.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Any Nonresident Manufacturer desiring to transport beer into this state in vehicles owned or leased by the Nonresident Manufacturer

 

 

 

 

 

 

 

will be required to furnish a tax bond on Form 2-52.5 in the amount of $10,000.00. The tax bond must be submitted prior to transporting

 

 

 

 

 

 

 

the first shipment of beer. The bond must be executed by a Surety Company authorized to do business in Texas.

 

 

 

 

 

 

 

6. If applicant is a partnership, 100% of the interest in the partnership must be accounted for among the partners listed. If one or more of

 

 

 

 

 

 

 

your general or limited partners is a limited partnership or limited liability partnership, complete an additional Form L-106-PC for each

 

 

 

 

 

 

 

partnership. If one or more of your general or limited partners is a corporation, complete Form L-106-PC for each corporation or limited

 

 

 

 

 

 

 

liability company.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. If applicant is a publicly held corporation, provide pertinent information as indicated in 2 on L-106-PC on all stockholders holding 5% or

 

 

 

 

 

 

 

more of the shares.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THE FOLLOWING INFORMATION IS FOR TABC HEADQUARTERS USE ONLY.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DO NOT ENTER ANYTHING BELOW THIS BOX

 

 

 

 

 

 

 

 

ONLY

 

 

 

NOTE: TAX SECURITY BS – ONLY REQUIRED IF QUESTION 11D IS ANSWERED “YES.”

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TABC

 

 

 

CITY, STATE, ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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