Form Ttb F 5100.11 - Withdrawal Of Spirits, Specially Denatured Spirits, Or Wines For Exportation Page 2

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PART III - PROPRIETOR’S REPORT OF INSPECTION AND TAX LIABILITY

The spirits described on Page 1 were inspected, as repor ted below, and have been prepared for withdrawal as required by regulations.

16. WITHDRAWAL IS FROM:

17.

PACKAGE GAUGE

RECORD ATTACHED

PRODUCTION ACCOUNT

STORAGE ACCOUNT

PROCESSING ACCOUNT

18.

CONTAINERS (Leave blank if no change)

TAXABLE

TAX

QUANTITY

GALLONS

NUMBER

IDENTIFICATION

LIABILITY

DETERMINED BY

(a)

(b)

(c)

(d)

GAUGE FOR

INSPECTION

WITHDRAWAL

REGAUGE AFTER REDUCTION IN

PROOF

19. DATE

20. PROPRIETOR OF DISTILLED SPIRITS PLANT

20a. BY (Signature and title)

PART IV - CERTIFICATE OF REMOVAL OF WINE FROM BONDED WINE CELLAR (Complete only if approval of application is required)

I certify that the wines described above

21. REMOVED FROM BONDED WINE CELLAR

22. SERIAL NUMBERS OF CONTAINERS

were removed for the purpose stated in

NO.

Item 6.

23. DATE REMOVED 24. PROPRIETOR OF BONDED WINE CELLAR

24a. BY (Signature and title)

PART V - CUSTOMS OFFICER’S REPORT OF INSPECTION AND LADING, SHIPMENT, OR RECEIPT

25. NOT INSPECTED (Give reason for not inspecting)

25a. INSPECTED AND FOUND TO BE AS DESCRIBED

EXCEPT AS NOTED IN ITEM 31

26. RECORDS OF DELIVERING AND EXPORTING CARRIERS SHOW THAT CONTAINERS OF SIMILAR DESCRIPTION

27. LADEN ON (Date)

WERE RECEIVED BY THE EXPORTING CARRIER FOR DELIVERY TO THE FOREIGN PORT NAMED IN ITEM 6

AND WERE LADEN ON BOARD THE EXPORTING CONVEYANCE AS REPORTED IN THIS FORM.

ON BOARD: VESSEL (Name)

AIRCRAFT (Name, symbols, number)

28. LADEN FOR

EXPORT

USE AS

RAILROAD CAR (Number)

TRUCK (State license)

SUPPLIES

29. RECEIVED IN

(No. or Location)

30. SHIPPED TO (Frontier port)

SERIAL NUMBER ON SEAL USED

CMBW

FTZ

CBW

31. DISCREPANCY OR SHORTAGE

32. DATE

33. PORT

34. SIGNATURE AND TITLE OF CUSTOMS OFFICER/WAREHOUSE PROPRIETOR

PART VI - CUSTOMS OFFICER’S REPORT OF THROUGH SHIPMENT AT FRONTIER PORT

35. FRONTIER PORT

36. DATE RECEIVED 37. INSPECTION DISCLOSED

NO EVIDENCE OF TAMPERING

SEALS INTACT

SEALS BROKEN (See item 38)

38. DETAILS OF DISCREPANCIES, TRANSSHIPMENT, RESEALING, ETC.

39. THE EXPORTING CONVEYANCE IDENTIFIED IN ITEM 28, BEARING THE SHIPMENT DESCRIBED

Foreign Port

IN PART I, WITH EXCEPTIONS AS NOTED IN ITEMS 31 AND 38 CLEARED FROM THIS PORT FOR

THE PORT OF

40. DATE

41. SIGNATURE AND TITLE OF CUSTOMS OFFICER

PART VII - CERTIFICATE OF CLEARANCE OR USE

42. THE EXPORTING CONVEYANCE BEARING THE SHIPMENT DESCRIBED IN PART I, WITH EXCEPTIONS AS NOTED ABOVE --

CLEARED FROM PORT OF

ON (Date)

BOUND FOR (Foreign port)

43. THE SPIRITS OR WINES DESCRIBED HAVE BEEN USED AS SUPPLIES ON THE AIRCRAFT OR FISHING VESSEL IDENTIFIED ABOVE AND

THE REQUIRED EVIDENCE OF THEIR USE HAS BEEN RECEIVED.

44. DATE

45. SIGNATURE OF DISTRICT DIRECTOR OF CUSTOMS

PART VIII - CERTIFICATE OF RECEIPT BY ARMED FORCES OFFICER

The distilled spirits or wines, described in Part I, with exceptions as noted in Item 47, w ere received for export to the Ar med Forces of the United States.

The spirits or wines will not be shipped f or consumption or use to an y place subject to application of the Internal Revenue laws of the United States .

46. DATE

47. DISCREPANCY

48. SIGNATURE

49. RANK

50. TITLE

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TTB F 5100.11 (10/2009)