Fillable Form 19: MONTHLY REPORT OF RETAIL LICENSE ACTIVITY (Comptroller of Maryland)

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Form 19: MONTHLY REPORT OF RETAIL LICENSE ACTIVITY (Comptroller of Maryland)

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COM-FED/RLS-19 Rev.09/19
MARYLAND
FORM
19
MONTHLY REPORT
OF RETAIL LICENSE
ACTIVITY
A. This monthly report of license issuing authorities covering alcoholic beverage licenses is to be led by the 15th of the month
following the month covered in the report. Mail the original and retain a copy for your les.
B. Signature of Issuing Authority only required on page 1 of monthly submission
C. Type or Print
D. List add, change and delete transactions on the reverse side.
E. Precede the Central Registration Number with a two-digit county code (i.e. Allegany County, use 01-12345678). The county
codes appear below.
F. It may be necessary to complete more than one type of transaction. A transfer of a license would be considered a DELETE and
an ADD. Delete the outgoing license and add the incoming license.
G. If any of the following occur, use ADD:
a. New License issued; or
b. New license issued due to license transfer (DELETE the previous license)
H. If any of the following occur, use DELETE:
a. Canceled or revoked license;
b. License not renewed; or
c. License canceled due to transfer to new license (ADD the new license)
I. If any of the following occur, use CHANGE:
a. Change of one or more ocers of the corporation;
b. Name change;
c. Change in location; or
d. Other information that has changed (e.g. phone number)
INSTRUCTIONS
CODE PREFIX CITY/COUNTY CODE PREFIX CITY/COUNTY
01 Allegany County 14 Howard County
02 Anne ArundelCounty 15 Kent County
03 Baltimore County 16 Montgomery County
04 Baltimore City 17 Prince George’s County
05 Calvert County 18 Queen Anne’s County
06 Caroline County 19 St. Mary’s County
07 Carroll County 20 Somerset County
08 Cecil County 21 Talbot County
09 Charles County 22 Washington County
10 Dorchester County 23 Wicomico County
11 Frederick County 24 Worcester County
12 Garrett County 25 City of Annapolis
13 Harford County
COM-FED/RLS-19 Rev.09/19
MARYLAND
FORM
19
MONTHLY REPORT
OF RETAIL LICENSE
ACTIVITY
Type of Transaction(s): Add Delete Change
Central Registration Number:___________________________ City or County License Number: _________________________
Class and Type of License: On O Transaction Date: ____________________________________
Entity or Corporate Name ___________________________________________________________________________________
Trade Name ______________________________________________________________________________________________
Retailer’s Address: _________________________________________________________________________________________
Licensee 1: ________________________________________ Licensee 2: ____________________________________________
Licensee 3: ________________________________________ Retailer’s Telephone Number: _____________________________
Remarks: ________________________________________________________________________________________________
________________________________________________________________________________________________________
Type of Transaction(s): Add Delete Change
Central Registration Number:___________________________ City or County License Number: _________________________
Class and Type of License: On O Transaction Date: ____________________________________
Entity or Corporate Name: ___________________________________________________________________________________
Trade Name: ______________________________________________________________________________________________
Retailer’s Address: _________________________________________________________________________________________
Licensee 1: ________________________________________ Licensee 2: ____________________________________________
Licensee 3: ________________________________________ Retailer’s Telephone Number: _____________________________
Remarks: ________________________________________________________________________________________________
________________________________________________________________________________________________________
Type of Transaction(s): Add Delete Change
Central Registration Number:___________________________ City or County License Number: _________________________
Class and Type of License: On O Transaction Date: ____________________________________
Entity or Corporate Name: ___________________________________________________________________________________
Trade Name: ______________________________________________________________________________________________
Retailer’s Address: _________________________________________________________________________________________
Licensee 1: ________________________________________ Licensee 2: ____________________________________________
Licensee 3: ________________________________________ Retailer’s Telephone Number: _____________________________
Remarks: ________________________________________________________________________________________________
________________________________________________________________________________________________________
Page _____ of ______
In accordance with the provisions of the Annotated Code of Maryland, Alcoholic Beverages Article (we/I) herewith
submit a true and complete report of all alcoholic beverage license transactions authorized by this oce for the month
ending _______________________ 20______ . This report has been examined by me and I acknowledge same to
cover all new licenses issued, all changes and all deletes (aecting licenses previously issued) for the month stated.
Signature of Issuing Authority Title of Issusing Authority
City or County
Date
Contact Information:
Comptroller of Maryland
Field Enforcement Division
Regulatory & Licensing
Section
P.O. Box 2999,
Annapolis, MD
21404-2999
410-260-7314 or 800-MD-TAXES
ATT@
marylandtaxes.gov
www.marylandtaxes.gov
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Form 19: MONTHLY REPORT OF RETAIL LICENSE ACTIVITY (Comptroller of Maryland)

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Completed 14 August 2020

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