Fillable Wholesaler Afdavit of Compliance (Summit County Government)

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Wholesaler Afdavit of Compliance (Summit County Government)

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DR 8004 (09/28/18)
COLORADO DEPARTMENT OF REVENUE
Liquor Enforcement Division
(303) 205-2300
Wholesaler Afdavit of Compliance
Section 44-3-303(1)(d), C.R.S.
Wholesaler Licensee Name (If an LLC; partnership; corporation or name of corporation) License Number
Trade Name of Establishment/Doing Business As (DBA) Phone Number
( )
Physical Address City State ZIP
Email Address
Transferor Retailer Licensee Name License Number
Trade Name of Establishment/Doing Business As (DBA) Phone Number
( )
Physical Address City State ZIP
The above wholesaler afrms that all alcohol beverages delivered to the above transferor retailer are:
Paid in Full (only for the purposes of complying with section 44-3-303(1)(d), C.R.S.)
Note: If Paid in full is selected, the wholesaler may no longer extend credit to the transferee or transferor until the
local and state licensing authorities have approved the transfer of the liquor license.
Not Paid in Full
Wholesaler:
Signature Print Title Date
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Wholesaler Afdavit of Compliance (Summit County Government)

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Completed 6 August 2020

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