Delinquency Form

Distributor Name

Distributor License Number

Retailer IL License Number

Please Enter all 10 positions, including the hyphen, as in the following example: 1A-0001234

Delinquent Corporation

Street Address

City

Date of Delinquency/Cure

Status

Delinquent

Cured

Note

Legal Agreement

I certify the above retailer has an outstanding debt for the purchase of wine or spirits which remains unpaid more than 30 days. Reporting a delinquency without a reasonable basis is a violation of the Act and could result in a license violation.

I certify the above referenced retailer has cured the previously reported delinquency. I acknowledge that removing the retailer from the delinquency list without a legal basis to do so is a violation of the Act and could result in a license violation.

You must certify to one of the following:

Attachments

Multiple files can be uploaded by holding down Shift or Ctrl while selecting.