Delinquency Form

Distributor Name

Distributor License Number

Retailer IL License Number Please Enter all 10 positions, including the hyphen, as in the following example: 1A-0001234

Delinquent Corporation

Street Address

City

Date of Delinquency/Cure

Status

Note

Legal Agreement You must certify to one of the following:

I certify the above retailer has an outstanding debt for the purchase of wine or spirits which remains unpaid more than 30 days. Reporting a delinquency without a reasonable basis is a violation of the Act and could result in a license violation.
I certify the above referenced retailer has cured the previously reported delinquency. I acknowledge that removing the retailer from the delinquency list without a legal basis to do so is a violation of the Act and could result in a license violation.

AttachmentsMultiple files can be uploaded by holding down Shift or Ctrl while selecting.

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Illinois Liquor Control Commission

Mon-Fri, 8:30am–4:30pm
50 W. Washington St, Suite 209
Chicago, IL 60602
P: 312.814.2206
F: 312.814.2241

Mon-Fri, 8:30am–4:30pm
300 W. Jefferson St, Suite 300
Springfield, IL 62702
P: 217.782.2136
F: 217.524.1911

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