Application for a Special Permit to Import Household Effects/Gifts into Massachusetts
(M.G.L. Chapter 138, Section 22A)
My age at present is
Signature Date
Title
*If additional space is needed, please use the last page*
I hereby apply for a Special Permit to import alcoholic beverages into Massachusetts from:
These beverages were acquired as:
HOUSEHOLD EFFECTS GIFT
years of age; I am
FemaleMale
ZipStateCity/Town:Massachusetts Residential Address:
Telephone Number:
Destination Address of Alcoholic Beverages to be Imported:
ZipStateCity/Town:
ZipStateCity/Town:Address:
If shipment is part of household effects, state previous address:
If shipment is a gift, state donor's name, address and telephone number:
Donor Name Donor Address Donor Telephone Number
The inventory details shall contain, with respect to each item, the exact brand or trade name, capacity of package, nature of
contents, age and proof where stated on the label.
Brand/Trade Name Capacity of Package Type of Contents Age and Proof
*If additional space is needed, please use the last page*
Under pains and penalty of perjury, I certify that these beverages are for personal use, not for resale, and were not acquired by purchase.
Email Address:
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