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OMB No. 1512-0117 (09/30/2002)

DEPARTMENT OF THE TREASURY

FOR ATF USE ONLY

BUREAU OF ALCOHOL, TOBACCO AND FIREARMS

CLAIM NUMBER

DATE OF AUDIT

CLAIM FOR DRAWBACK OF TAX ON TOBACCO PRODUCTS, CIGARETTE

PAPERS AND CIGARETTE TUBES

AUDITED BY

(See Instructions on back)

PART I - REQUEST FOR INSPECTION

1. CHECK ONE

These articles taxpaid under

26 U.S.C. 5701. (Produced in

26 U.S.C. 7652(a). (Produced

26 U.S.C. 7652(b). (Brought

U.S.A. or a foreign country)

in Puerto Rico)

in from U.S. Virgin Islands)

2. TO BE SHIPPED TO (Name and Address)

TO:

National Revenue Center

Bureau of Alcohol, Tobacco and Firearms

8002 Federal Office Building

550 Main Street

Cincinnati, Ohio 45202-3263

I request that an officer of the Bureau of Alcohol, Tobacco and Firearms be assigned to inspect tobacco products, cigarette papers, or cigarette tubes, on

which I have paid the tax, and which are to be shipped to a foreign country, Puerto Rico, the U.S. Virgin Islands, or a possession of the United States

with benefit of drawback of tax, as provided for by the regulations in 27 CFR, Part 290.

3. LOCATION WHERE ARTICLES ARE HELD (Number, street, city or town, State and ZIP Code)

4. NAME AND MAILING ADDRESS OF TAXPAYER (Street address, P.O. Box or R.F.D. number, city, State and ZIP Code)

5. SIGNATURE OF TAXPAYER (if officer of corporation, give title)

6. TAXPAYER’S EMPLOYER IDENTIFICATION

7. DATE

NUMBER

PART II - CLAIM

8. SCHEDULE OF ARTICLES FOR EXPORT

NUMBER

KIND OF

SALE

NUMBER OF

TOTAL

TOTAL PRICE

RATE

AMOUNT

MARKS &

ARTICLES

PRICE

POUNDS/

NUMBER

Col. (d) x Col. (f) ÷

OF TAX

NUMBERS ON

CONTAINERS

(Small cigarettes,

PER 1,000

OUNCES IN

OR POUNDS/

1,000

CLAIMED

SHIPPING

CONTAINERS

Large cigars, Chewing

EACH

OUNCES

Tobacco, Snuff, etc.)

CONTAINER

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

ROLL-YOUR-OWN TOBACCO

PIPE TOBACCO

CIGARS

TOTAL

CIGARETTES

CHEWING TOBACCO

SNUFF

Complete only for large cigars. Enter the taxable sale price per thousand.

Complete only for large cigars with a sale price of not more than $235.294 per thousand.

Under penalties of perjury I declare that this claim for drawback of internal revenue tax is, to the best of my knowledge and belief, true and accurate; I

have paid the tax on the tobacco products, cigarette papers, or cigarette tubes, to be shipped to a foreign country, Puerto Rico, the U.S. Virgin Islands, or

a possession of the United States, or to foreign-trade zone; no other allowance of drawback has been made or claimed on the tobacco products,

cigarette papers, or cigarette tubes or any part thereof; and I am justly entitled to a drawback of tax.

9. SIGNATURE OF CLAIMANT

11. DATE

10. TITLE OR STATUS (State whether individual owner, member

of firm, or if officer of corporation, give title)

PART III - ATF OFFICER’S REPORT OF INSPECTION

I have inspected the articles and find that Part II, Item 8, is complete and accurate; the packages of tobacco products, cigarette papers, or cigarette tubes,

have attached thereto the required label; the articles were packed under my supervision in shipping containers; and each container has been marked and

numbered, as indicated in Part II, Item 8, and released to the claimant for export.

ATF F 5620.7 (11-99) (Formerly ATF F 2147 (5620.7), which is obsolete)