Snuff (Pounds)
Pipe Tobacco (Pounds)
Roll Your Own Tobacco
Cigarette Papers (Number)
Cigarette Tubes (Number)
(f)
(g)
(Pounds)
(Read instruction J)
(j)
(h)
(i)
7. On Hand, in Bond, Start of Period
8. Manufactured
9.
a. From other factories
NO ENTRY
NO ENTRY
b. From customs custody
NO ENTRY
NO ENTRY
NO ENTRY
(1) Puerto Rico
(2) Other than Puerto Rico
c. From export warehouses
d. From foreign trade zones
10. Received by Return to Bond
11. Overages Disclosed by Inventory
12. Other (Specify)
13. TOTAL
14. Removed Subject to Tax
15.
a. For export
b. To export warehouses
c. To other factories
d. To foreign trade zones
e. For use of United States
(Read instruction H)
f. For experimental purposes off factory
premises
16.
a. Consumption by employees off factory
NO ENTRY
NO ENTRY
premises
b. Consumption by employees on factory
NO ENTRY
NO ENTRY
premises
c. Use for experimental purposes on
NO ENTRY
NO ENTRY
factory premises
d. Loss
e. Destruction
f. Reduction to tobacco
NO ENTRY
NO ENTRY
17. Shortages Disclosed by Inventory (Read
instruction I.)
18. Other (Specify)
19. On Hand, in Bond, End of Period
20. TOTAL
21. Large Cigars Removed Subject to Tax (Sum of a. and b. should agree with item 14(a))
a. Number Removed with Sale Price Per Thousand of $763.222 or Less
b. Number Removed with Sale Price Per Thousand of More Than $763.222
UNDER PENALTIES OF PERJURY, I DECLARE THAT, TO THE BEST OF MY KNOWLEDGE AND BELIEF, THIS REPORT IS TRUE, ACCURATE, AND COMPLETE .
22. Signature (Read instruction K.)
23. My Title for This Business (Examples: owner, partner, corporate title, or power of attorney.)
24. Date
25. My Business Telephone Number
26. My E-Mail Address
How do I file this form? Send this form to the TTB Tobacco Unit, 550 Main St, Ste 8002, Cincinnati, OH 45202-5215
TTB F 5210.5 (03/2010)