Form Ttb F 5154.2 - Supporting Data For Nonbeverage Drawback Claims - 2016

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OMB No. 1513-0098 (05/31/2016)
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)
SUPPORTING DATA FOR NONBEVERAGE DRAWBACK CLAIMS
PAGE_____OF____
(PLEASE READ INSTRUCTIONS BELOW BEFORE COMPLETING THIS FORM)
PART I - IDENTIFICATION DATA
1. NAME AND ADDRESS OF CLAIMANT
2. PERIOD COVERED (Check one)
QUARTER
MONTH
ENDING:___________________________
PART II - DISTILLED SPIRITS ACCOUNT (IN PROOF GALLONS, EXCEPT LINES 1-2)
SPIRITS RECOVERED
Was a physical inventory taken per 27 CFR 17.167(a)?
Eligible Spirits Content of Intermediate
New Spirits (eligible, not previously
In the Manufacture
In the Manufacture of Intermediate
(Check one)
Products
used in intermediate or nonbeverage
of Nonbeverage
Products (eligible spirits)
products)
Products (ineligible
Yes
No
spirits)
(a)
(b)
(c)
(d)
1. KIND (optional, except for Puerto Rican or U.S. Virgin
Islands spirits, and imported rum)
2. EFFECTIVE TAX RATE PER PROOF GALLON
$
$
$
$
$
$
3. ON HAND, START OF PERIOD
4. IN PROCESS, START OF PERIOD
5. RECEIVED
DURING
PERIOD:
6. RECOVERED
7. PRODUCED
8. GAINS
9. TOTAL TO ACCOUNT FOR (add lines 3-8)
10. USED IN NONBEVERAGE PRODUCTS
DURING
11. USED IN INTERMEDIATE PRODUCTS
PERIOD:
12. OTHERWISE USED (not subject to drawback)
13. LOSSES
14. ON HAND, END OF PERIOD
15. IN PROCESS, END OF PERIOD
16. TOTAL ACCOUNTED FOR (add lines 10-15)
TTB F 5154.2 (11/2014)

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