Form Atf F 5630.5 - Special Tax Registration And Return Alcohol And Tobacco
ADVERTISEMENT
1
2OMB NO. 1512-0472 ( 09/30/2002)
DEPARTMENT OF THE TREASURY
BUREAU OF ALCOHOL, TOBACCO AND FIREARMS
SPECIAL TAX REGISTRATION AND RETURN
ALCOHOL AND TOBACCO
(Please Read Instructions on Back Carefully Before Completing This Form)
SECTION I - TAXPAYER IDENTIFYING INFORMATION
1. EMPLOYER IDENTIFICATION NUMBER (Required see
2. BUSINESS TELEPHONE NUMBER
FOR ATF USE ONLY
instructions)
(
)
3. NAME (Last, First, Middle)
or
CORPORATE NAME (If Corporation)
T
FF
4. TRADE NAME
FP
5. MAILING ADDRESS (Street address or P.O. box number)
I
T
6. CITY
STATE
ZIP CODE
9. TAX PERIOD COVERING
ACTUAL LOCATION (IF DIFFERENT THAN ABOVE)
7. PHYSICAL ADDRESS OF PRINCIPAL PLACE OF BUSINESS (Show street address)
FROM: _______________
(mm/dd/yy)
8. CITY
STATE
ZIP CODE
TO: June 30, ________
(yy)
SECTION II - TAX COMPUTATION
TAX CLASS DESCRIPTION (FOR ITEMS MARKED*, SEE INSTRUCTIONS)
MONTHLY
ANNUAL
LOCATIONS
TAX DUE
CODE
(c)
(a)
(b)
(d)
(e)
(f)
RETAIL
$20.83
1
$250
Liquors (Distilled spirits, wine or beer)
/
11
3
DEALER
1
/
Beer only
$20.83
250
12
3
Liquors (Distilled Spirits, Wine or Beer) - at large
1
$20.83
/
250
15
3
16
Beer only - at large
$20.83
1
/
250
3
WHOLESALE
2
Distilled spirits, wine or beer
$41.66
/
500
31
3
DEALER
2
/
Beer only
$41.66
500
32
3
1
BREWER
Regular rate
$83.33
/
1000
41
3
2
/
REDUCED rate*
$41.66
500
43*
3
500
51
NONBEVERAGE DRAWBACK CLAIMANT
1
INDUSTRIAL
$20.83
/
250
User of specially denatured alcohol
55
3
ALCOHOL
1
/
250
$20.83
56
Dealer in specially denatured alcohol
3
1
$20.83
/
250
57
User of tax-free alcohol
3
ALCOHOL
1
/
Proprietor of alcohol fuel plant
$83.33
1000
58
3
PRODUCERS
2
/
$41.66
500
Proprietor of alcohol fuel plant - REDUCED*
59*
3
1
/
1000
81
$83.33
Proprietor of distilled spirits plant
3
2
/
Proprietor of distilled spirits plant - REDUCED*
$41.66
500
86*
3
1
Proprietor of bonded wine cellar
$83.33
/
1000
82
3
2
/
500
Proprietor of bonded wine cellar - REDUCED*
$41.66
87*
3
1
/
$83.33
1000
83
Proprietor of bonded wine warehouse
3
2
/
$41.66
88*
500
Proprietor of bonded wine warehouse - REDUCED*
3
1
/
1000
Proprietor of taxpaid wine bottling house
$83.33
84
3
2
/
Proprietor of taxpaid wine bottling house - REDUCED*
$41.66
500
89*
3
1
/
TOBACCO
Manufacturer of tobacco products
$83.33
1000
91
3
PRODUCTS
2
/
Manufacturer of tobacco products - REDUCED*
$41.66
500
95*
3
1
/
92
Manufacturer of cigarette papers and tubes
$83.33
1000
3
2
/
500
96*
$41.66
Manufacturer of cigarette papers and tubes - REDUCED*
3
Proprietor of export warehouse
1
$83.33
/
1000
93
3
2
/
Proprietor of export warehouse - REDUCED*
$41.66
500
97*
3
TOTAL TAX DUE $
MAKE CHECK OR MONEY ORDER PAYABLE TO "BUREAU OF ALCOHOL, TOBACCO AND FIREARMS", WRITE YOUR EMPLOYER
IDENTIFICATION NUMBER ON THE CHECK AND SEND IT WITH THE RETURN TO BUREAU OF ATF, P.O. BOX 371962, PITTSBURGH,
PA 15250-7962.
Under penalties of perjury, I declare that the statements in this return/registration are true and correct to the best of my knowledge and belief; that this return/registration applies only to the
specified business and location or, where the return/registration is for more than one location, it applies only to the businesses at the locations specified on the attached list. Note: Violation
of Title 26, United States Code 7206, is punishable upon conviction by a fine of not more than $100,000 ($500,000 in the case of a corporation) or imprisonment for not more than 3 years, or
both, with the costs of prosecution added thereto.
SIGNATURE
TITLE
DATE
ATF F 5630.5 (10-99) PREVIOUS EDITIONS ARE OBSOLETE
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