Fillable 10-9 - PERMIT APPLICATION CHARITY WINE AUCTION MARYLAND (Comptroller of Maryland)

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10-9 - PERMIT APPLICATION CHARITY WINE AUCTION MARYLAND (Comptroller of Maryland)

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MARYLAND
FORM
10-9
CHARITY WINE AUCTION
PERMIT APPLICATION
COM/FED RLS 10-9 Rev. 09/19
Oce Use Only
Permit Number __________
Permit Year _____________
Stub Number ___________
Approved ______________
Date Issued ____________
Check Number __________
Check Amount $ ________
Deposit Date____________
Section 1
A. Name of Charitable Organization _______________________________________________
B. Mailing Address ____________________________________________________________
C. Telephone number __________________________________________________________
D. Premises in Maryland where event is to be held ___________________________________
_________________________________________________________________________
E. Is this a retail license premise? ................................ Yes No
F. Date event is to be conducted _________________________________________________
G. FederalIdenticationNumber .........
-
H. Social Security number of organization
(OcialMakingApplication) ..........
- -
Section 2
A. Has the applicant ever been convicted of a felony by any state or federal court? ........................
Yes No
B. Does the applicant agree to conform to all the laws, rules and regulations of the state of Maryland relating to the
business in which he proposes to engage under this permit? ......................................
Yes No
C. Does the applicant authorize the Comptroller of Maryland and his duly authorized personnel to search without
warrant any vehicle, railroad cars, vessel, aircraft or premises used in the business to be conducted under this
permit at any and all hours agreeable to the laws of the state of Maryland? ...........................
Yes No
D. Has the applicant ever been convicted of a violation of the law of the United States, Maryland or any other state
concerning alcoholic beverages, gaming, or gambling? ..........................................
Yes No
(Ifyes,explainindetailonseparatepaper-listoense,court,date,etc.)
E. The Annotated Code of Maryland, Alcoholic Beverages Article, Section 1-404 titled “Compliance with Workers’
CompensationAct”requirestheevidenceofsuchcompliancepriortotheissuanceofanypermitbythisoce.
Theapplicantherebyarms(checkone):
a. the applicant is not an employer required to provide coverage by the Maryland Workers’ Compensation Law; or
b. the applicant is an employer required to provide employee coverage by the Maryland Workers’ Compensation Law and has
securedsuchcoverage.Asevidenceofsuchcoverage,thefollowingissubmitted:
1. Name of insurance company _________________________________________
2. Policy or binder number _____________________________________________
Section 3
Physical description of premises applied for _______________________________________________________________________
__________________________________________________________________________________________________________
The Premises is owned by _____________________________________________________________________________________
whose mailing address is ______________________________________________________________________________________
__________________________________________________________________________________________________________
(I/We)certifythat(Iam/weare)theowner(s)oftheabovedescribedpremises,and(I/we)herebyconsenttotheuseofthepremises
intheconductofthebusinessestobeengagedinunderthepermitappliedforand(I/we)authorizetheComptrollerofMarylandand
his duly authorized inspectors to inspect and search without warrant, the premises so described at any and all hours.
WITNESS(my/our)hand(s)this ____________ day of ___________________________________ 20 ______________
WITNESS _____________________________________________________________
_______________________________________________________________
Owner’s signature
WITNESS _____________________________________________________________
_______________________________________________________________
Owner’s signature
MARYLAND
FORM
10-9
CHARITY WINE AUCTION
PERMIT APPLICATION
COM/FED RLS 10-9 Rev. 09/19
Contact Information
Comptroller of Maryland
Field Enfo
rcement Division
Regulatory & Licensing Section
P.O. Box 2999
Annapolis, Maryland 21404-2999
410-260-7314 or 800-MD-TAXES
ATT@marylandtaxes.gov
www.marylandtaxes.gov
Section 4
A. Permitfeeis$10.00(remittedherewith)
B. Prepaymentoftaxes:
Withinseven(7)daysofthedateoftheauction(seeSection1F),applicantmustremitanestimatedprepaymentofthewinetax
on wine anticipated to be sold at auction on which the tax has not already been paid.
Note:Within30daysfromthedateoftheauction,ourreportForm533-1istobesubmittedtotheRevenueAdministration
Division.
Section 5
A. Extract from the Maryland Law:Ifanysignedstatement,report,adavit,oroathrequiredundertheprovisionsofthe
AnnotatedCodeofMaryland,AlcoholicBeveragesArticleshallcontainanyfalsestatement,theoendershallbedeemedguilty
of perjury and upon conviction thereof, shall be subject to the penalties provided by the law for that crime.
By my signature below, I understand that while I am making this application on behalf of the listed charitable organization, I will
beconsideredaco-applicantandassuchwillbeheldpersonallyaccountableforlingreportForm533-1,payingtheapplicable
excise tax and otherwise complying with the provisions of the Annotated Code of Maryland, Alcoholic Beverages Article.
Signature of applicant(ifacorporation,thePresident,VicePresident,orSecretary-Treasurer)
________________________________________________ ____________________________________________
B. State of ______________________________________________________________________________________________
County of _____________________________________________________________________________________________
This is to certify that on the ______ day of ___________________ 20 ______, before me the subscriber, a ____________ in
andfortheStateof______________________personallyappearedwhorepresentedhimself(herself)tobe______________
___________________________________________________________ of the _____________________________________
Owner,partnerortitleofcorporateocer Tradeorcorporatename
andmadeoathindueformofthelawthatthestatementscontainedhereinaretrueandcorrecttothebestofhis(her)
knowledge and belief.
Whereof Witness My Hand and Seal ____________________________________________________
(Seal) Oceradministeringoath
Page 2
CorporateOcer OrganizationalOcial
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10-9 - PERMIT APPLICATION CHARITY WINE AUCTION MARYLAND (Comptroller of Maryland)

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Completed 14 August 2020

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