Form Ttb F 5100.11 - Withdrawal Of Spirits, Specially Denatured Spirits, Or Wines For Exportation

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OMB No. 1513-0037 (01/31/2012)

DEPARTMENT OF THE TREASURY

1. SERIAL NO. (Begin with

“1” each Jan. 1)

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)

WITHDRAWAL OF SPIRITS, SPECIALLY DENATURED SPIRITS, OR WINES FOR EXPORTATION

Please read Instructions after Page 2 before completing this form.

PART I - APPLICATION OR NOTICE

2. APPLICATION IS MADE TO

3. NOTICE GIVEN OF

WITHDRAW SPIRITS OR WINES

WITHDRAWAL OF SPECIALLY

WITHDRAWAL OF SPIRITS OR WINES

WITHOUT PAYMENT OF TAX

DENATURED SPIRITS FREE OF TAX

WITHOUT PAYMENT OF TAX

4. WITHDRAWAL FROM

OPERATED BY

5. ADDRESS OF DIRECTOR, NATIONAL REVENUE CENTER

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

BWC. ______________________

550 MAIN ST, STE 8002

DSP. _______________________

CINCINNATI, OH 45202-5215

6. PURPOSE

SHIPMENT FOR

FOR EXPORTATION TO (Name the foreign port and country)

TRANSFER TO (Number or name and location)

OF WITH-

EXPORT TO ARMED

DRAWAL

FORCES OF THE U.S.

CMBW

FTZ

CBW

(Make

Applicable

Entries)

USE AS SUPPLIES ON VESSELS

AIRCRAFT

7. CONSIGNED TO OR IN CARE OF (Make applicable entries)

DIRECTOR OF CUSTOMS AT PORT OF (Specify)

TRANSPORTATION OFFICER (Name) (Location)

CUSTOMS OFFICER/WAREHOUSE PROPRIETOR OF

CMBW

FTZ

CBW

(Location)

8. NAME OF DOMESTIC CARRIER

9. NAME OF EXPORT CARRIER

10. DESCRIPTION OF SPIRITS OR DENATURED SPIRITS AND CONTAINERS (Columns a, d, e, and f only are required for denatured spirits)

PRODUCED BY

FILLED BY

CONTAINERS

2 /

KIND

NAME

DSP NO.

NO. AND TYPE

IDENTIFICATION

(a)

(b)

(c)

(d)

(e)

(f)

11. DESCRIPTION OF WINES AND CONTAINERS

CONTAINERS

KIND

PERCENT

BOTTLES

SIZE OF

WINE

TAX

ALCOHOL

NO. AND TYPE

SERIAL NUMBER

PER CASE

BOTTLES

GALLONS

LIABILITY

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

Under the penalties of perjury, I declare that the spirits, denatured spirits, or wines described above are truly intended to (or have been) withdrawn for the purpose

indicated, in the manner prescribed in regulations, and will not be (have not been) shipped for the purpose of evading or delaying payment of any revenue tax thereon.

12. DATE

13. PRINCIPAL

13a. SIGNATURE

13b. TITLE

FOR TTB USE ONLY PART II - APPROVAL OF APPLICATION

14. DATE

15. SIGNATURE AND TITLE OF APPROVING OFFICER

Application is approved

with respect to the

required bond

State whether (a) vessel or aircraft operated by the United Slates; (b) vessel or aircraft engaged in foreign trade, or in trade between the United States and any of its possessions, or between

Hawaii or Alaska and any other part of the United states; (c) vessel of the United States engaged in trade between Atlantic and Pacific ports of the United Slates; (d) vessel of war of any foreign

nation; or (e) vessel employed in: (1) the fisheries; or (2) the whaling business. Show name of vessel, country of registry, and ports of call, or, if a whaling vessel, location of operations. If aircraft,

show also name of airline and country of registry of aircraft.

Also enter formula number for special denatured spirits.

Enter quantity of spirits in proof gallons or quantity of denatured spirits in wine gallons and check applicable box.

In Items 11(d) and 22 show filling date when use of that date is authorized instead of serial numbers on cases. Item 11(d) need not be completed when prior approval of application is required.

Show principal on bond under which withdrawal is made.

TTB F 5100.11 (10/2009)

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