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Alaska Annual Declaration of Anticipated Brewing Form

To avail of the reduced tax rate, the applicant must ensure that the State of Alaska’s Department of Revenue receives this form by May 31 (every year). Specifically, this form must be mailed to this address:Download

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0405-406  Rev 09/12 - page 1	
Phone: 907-269-6620
Fax:  907-269-6644	
Printed Name Printed Title	
EINTTB Registry #:
Business Name DBA (if applicable)
Mailing Address Physical Address of Brewery
Mailing City StateZip Physical City StateZip
Contact  Email Address Contact TelephoneFAX Number Physical Telephone	
July 1, _______ to June 30, _______	
To qualify for the Alaska reduced rate tax, this form MUST be received on or before May 31 each year.	
Type of Entity 
(check one) :	Individual	Partnership	Corporation	Limited Liability 
Corporation	Other __________________	
Please answer all of the questions below
1. Have you included a copy of your most recent Brewer’s Report of Operations (TTB F5130.09) dated in the current calendar 
year?  Yes  	
2. Has this brewery exceeded the 2 million barrel limit as set forth in 26 \
USC 5051(a)(2)?  Yes 	
3. Will this brewery ship to or sell more than 60,000 barrels in Alaska in the fiscal year July 1 to June 30?  Yes 	
4. Does this brewery operate more than one brewery?   Yes 	
5. Is this brewery a member of a controlled group of brewers?  Yes 
If you are a member of a controlled group of brewers, or you operate more than one brewery, include a list of the names and addresses 
of the other breweries and the TTB Registry Number for each below.  If more space is needed  please attach a separate sheet.
Member Brewery Name (dba) Physical AddressCityStateTTB Registry Number	
I will allow the Alaska Department of Revenue to disclose to the following Alaska Alcoholic Beverage Distributor that the above named 
breweries qualify for the reduced rate of tax as provided by AS 43.60.010(c) and in the event that sales of beer produced by the above 
named breweries meet or exceed 60,000 barrels in Alaska during the fiscal year (July 1 to June 30), I allow the Alaska Department of 
Revenue to inform the following distributor of the volume of  beer sold in Alaska prior to meeting or exceeding 60,000 barrels so the 
distributor may have time to adjust the sales price to account for the increase in tax. I also agree to a\
llow the Alaska Department of 
Revenue to publish our status as a reduced rate brewer on the department\
’s website.
Distributor’s Name Distributor’s Address
Signature of Owner or other Authorized Representative of the Brewery. I certify that I have the authority to execute this 
document on behalf of the brewery. I declare under penalty of perjury that this document has been examine\
d by me and, to 
the best of my knowledge and belief, is true, correct and complete.	
Mail to:  Alaska Department of Revenue, 550 W 7th Ave STE 500, Anchorage AK 99501-3555
Annual Declaration of Anticipated Brewing	

0405-406  Rev 09/12 - page 2	
Please list the brand names of all products your brewery intends to ship to or sell in Alaska and include the 
percentage of alcohol by volume for each product.  Attach additional sheets as necessary.
Product Brand Name	Percentage of Alcohol 
by Volume (ABV)
Page _____ of  _____
Annual Declaration of Anticipated Brewing	
Next: Alaska Cigarette and Tobacco Products Monthly Tax Return Form Previous: Alaska Alcoholic Beverage Excise Tax Return Form
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