Washington, DC 20226 &c tJ

DEPARTMENT
BUREAU
OF
OFALCOHOL,
THE
TREASURY
TOBACCO
Washington,
AND
DC 20226
FIREARMS
&c
tJ
~++JL
F:OlOOO:CEC
August
Linda A. Skiadany
Senior
Associate
Commissioner
Food and Drug Administration
5600 Fishers
Lane (HF-10)
Rockville,
M D 20857
30,
2002
MS.
RE:
Public
Law 107-88,
02N-0277,
and OZN-0278
Dear
Ms.
for
Docket
External
Nos.
Relations
02N-0276,
Skladany,
This letter
responds
to your request
for comments
regarding
Title
III,
Subtitle
A of the Public
Health
Secilrity
and B1:)terrorism
Preparedness
and Response
Act of 2002,
P llblic
Law 107-88,
(the Act of 2002).
The Act is dire(:ted
at protecting
the safety
and
security
of the nation's
food and drug supply
and
requires
in relevant
part
that
the Food and Drug
Administration
':FDA) impose certain
registration,
recordkeepinq,
and notice
requirements
to effect
its
purpose.
The Bureau of Alcohol,
Tobacco and Firearms
(ATF) regulates
the alcohol
beverage
industry
and
imposes many of the same requirements
upon the
industry
that
are required
under the Act of 2002.
This letter
identifies
these requirements
and
encourages
collaboration
between
our respective
agencies
to avoid
duplication
of efforts
and undue
burden
upon the alcohol
industry.
Background
As background,
section
305 of the Act of 2002 (Docket
No. 02N-0276)
requires
the registration
of domestic
and foreign
food facilities.
The registration
must
contain
information
necessary
to notify
the Secretary
of Health
and Human Services
(HHS) of the name and
address
of each fat ility,
trade
:ames under wh ich the
WWW.ATF.TREAS.GOV
7+
3
trade
address
of each facility,
facility
conducts
business
and,
HHS deems necessary,
the generai
names under which
when the Secretary
t.1:od category.
the
of
Section
306 of the Act of 21301 (Ds,.ket
No. OZN-0277)
the promulgation
of regui itions
to establish
requires
requirements
for the estabiishment
and maintenance
of
records
needed to determine
the im!mediate
previous
sources
and the immediate
subsequent
recipients
of
food,
which records
would be kept for no more than two
This section
would authorize
the Secretary
of
years.
HHS to have access
to these
records
when there
is a
reasonable
belief
that
an article
of food is
adulterated
and presents
a threat
of serious
adverse
health
consequences
or death to humans or animals.
Finally,
02N-0278)
consignee
shipments.
manufacturer
the time
regulations),
which the
of entry.
article's
section
307 of the Act (>f 2002 (Docket
No.
requires
that
the owner,
importer,
or
provide
prior
noticz
of imported
food
The notice
must identify
the article,
the
and shipper,
the grower
(if
known within
within
which notice
is required
under
the country
of origin,
the country
from
article
is shipped,
and +he anticipated
port
Providing
this
notice
is a condition
of the
admission
into
the United
States.
ATF-Enforced
Statutory
Registration
of
the
Requirements
Industry
Member
The Federal
Alcohol
Administrdtion
Act (FAA Act),
27
203, and implementing
regulations
in title
27
U.S.C.
imposes
many of the same requirements
as those
C.F.R.,
Specifically,
like
the
imposed
under the Act of 2002.
registration
requirements
in the Act of 2002, the FAA
Act and implementing
regulations
provide
that
it shall
except
pursuant
to a basic
permit
issued
be unlawful,
by the Secretary
of the Treasury,
to engage in the
business
of importing,
wholesaling,
producing,
The FAA
or rectifying
alcohol
beverages.
blending,
Act and implementing
regulations
identify
the limited
class
of persons
entitled
to a basic
permit
and
condition
the permit
upon compliance
with
all
Federal
This
27 U.S.C.
204.
laws relating
to alcohol.
requirement
is intended
to protect
the integrity
of
the
are
industry
likely
to
by ensuring
that
comply with
the
only those persons
who
law enter
the industry.
The basic
permit
approval
process
entails
a ,mclr.~layered
investigation
of the permit
applicant,
involving
verification
of citizenship
or business
visas
issued
by the Immigration
and Naturalizaticn
Service,
review
of the applicant's
business
structure
to discover
any hidden
ownership,
and investigation
investors
and owners through
multiple
criminal
databases
to discover
criminal
histories
and/or
affiliations.
of
In addition
to ensuring
the integrity
of the regulated
the permit
requirement,
along with
labeling
industry,
requirements
identifying
the bottler
or importer,
and
other
required
records
under the Internal
Revenue Code
(discussed
below),
facilitates
the
of 1986 (IRC)'
tracing
of product
to the responsible
party
(permittee)
in cases of a problem
with
the product.
z,*e.g.,
27 C.F.R.
1.20-l-22,
4.35a,
and 24.300,
et
In the case of imported
products,
while
the
seq.
foreign
producer
is not registered
with ATF, the
required
to produce
letters
fr:jm
importer
is routinely
the foreign
supplierabout the product
as part
of the
application
process.
We would also point
out that
State
liquor
control
boards
also require
that
persons
engaged in the
alcohol
beverage
business
obtain
a State
license,
application
standards,
for engaging
impose similar
business
in this
industry.
An FDA registration
requirement
for domestic
and foreign
facilities
producing
alcohol
beverages
would appear
to be
1 The IRC and
to establish
bonded winery
operations.
C.F.R.
Part
(Brewery).
to
process,
comply with
and
in
lmplementlng
regulations
require
that persons
'&ishing
operatrons
as a distilled
spirits
plant
(DSP),
must also qualify
to engage rn cilich
(BW), cJr brewer
See, e.y.
27 C.F.R.
Part 19 (DSP), Subpart
c-q; 17
24, ScbpartD
(BW); and 27 C.F.R.
Part 25, Subpart
G
The regulations
establish
a rrgorous
application
allow
ATF to evaluate
the applicant's
likelihood
to
the law.
crtatlons
in this
letter
refer
to wine,
.I .5lY.>,.ar
2While
the iegdi
regulatory
scheme applies
to hot-h dlstrlled
spirits
and malt
(except
that
no permit
is requ:red
f:r
beverages/beer
as well
brewers
of malt beverages).
duplicative
unnecessary.
of
existing
r-egis
-,~i' Ii
requirements
and
Recordkeeping
The recordkeeping
requirements
rL:qu,red
under section
306 of the Act of 2002 are sin:ii<jr
Ln nat:lre
and
purpose
to the recordkeeping
requirements
under the
wholesaler,
T .Ae Importer,
chapter
52.
IRC, 26 U.S.C.
and blender
of dlconol
beverages
are
producer,
required
to maintain
records
of production
and
27 CFR Part 24, Subpart
0 (wine);
27 CFR
importation.
spirits);
27 CFR Part
W (distilled
Part 19, Subpart
25, Subpart
U (beer);
27 CFR Part 251, Subpart
I
These
(imported
distilled
spirits,
wiile and beer).
to ensure
record
keeping
requirements
are intended
that
the tax due on the product
is paid,
or that
the
tax is not reimposed
upon the product
by virtue
of the
Therefore,
required
manner in which
it is disposed.
records
track
the product
from the point
of production
Thus,
or importation
to its
ultimate
disposition.
establish
the
required
records
under the IKC already
immediate
previous
sources
and tr.e immediate
subsequent
recipients
of the alco!.Lol
beverages,
as is
A requirement
that
the
required
by the Act of 2002.
same or similar
information
be maintained
under FDA
regulations
would be duplicative
and unnecessary.
Prior
Notice
As indicated
above,
section
3137 of the Act of 2002
requires
prior
notice
describing
tne article,
the
manufacturer
and shipper;
the grower
(if
known),
the
country
of origin,
and the country
tram which the
This
information
is also required
article
is shipped.
While
under regulations
implementing
the FAA Act.
there
is no formal
"prior
notice"
requirement
under
the information
collection
is
FAA Act regulations,
essentially
the same and serves
the same purpose.
the FAA Act requires
that
industry
In particular,
members apply
for and obtain
a certificate
of label
approval
(COLA) covering
the bottled
product
before
interstate
or foreign
is introduced
into
the product
to ensure
that
The COLA, which
is i-tended
commerce.
5
in a non-decept
identifies
the product
the product
contain
mandatory
alcohol
beverage
label
must
way,
which includes
the brand name of the
information,
the class
and type designation,
the al:-zr:;!
product,
the name and address
of the bottler
of
content,
packer
(domestic
product
or imported
bulk product
bottled
in the United
States)
or importer,
and tne
The COLA forms are valid
country
of origin.
provided
the beverage
content,
iabel
and
indefinitely,
importer
remain
the same.
the Act of 2002 does not define
"prior
Significantly,
notice"
and leaves
the amount of time required
to
satisfy
"prior
notice"
to be established
by
Since an approved
COLA form must be
regulation.
submitted
to Customs at the port
of entry
as a
condition
of releasing
the product
(see, e.g.,
27
we believe
the purpose
of the prior
C.F.R.
§ 4.40),
That is,
the
notice
requirement
is fully
satisfied.
purpose
of the prior
notice
requirement
is to enable
the Government
to establish
the identity
and origin
of
the product
prior
to the product's
importation
into
The submission
of the COLA forms as a
the country.
satisfies
this
purpose.
condition
to importation
Other
ATF Regulation
of
the
Industry
In addition
to the above,
ATF conducts
periodic
testing
of alcohol
beverages
and laboratory
analyses,
to ensure
product
integrity
and
as appropriate,
Numerous
compliance
with
applicable
regulations.
alcohol
beverage
products
will
not be issued
COLA
forms without
first
performing
a product
evaluation
ATF conducts
occasional
alcohol
the ATF Laboratory.
both targeted
and random,
testing
beverage
samplings,
the integrity
and regulatory
compliance
of alcohol
ATF also
beverage
products
on the market.
investigates
consumer
complaints
and, in consultation
voluntary
recalls
of the
with
the FDA, requests
product
where a health
concern
is presented.
After
attending
the Constituent
Roundtable:
Interagencies
meeting
on August
6, 2002, I followed
with
a telephone
call
to Ms. Leslye
M. Fraser,
(Associate
Director
for Regulations,
Office
of
Regulations
and Policy),
to discuss
the information
at
up
6
outlined
in this
memorandum
and encourage
the exchange
of information
and open dialogue
between
FDA and ATF,
to avoid
duplication
of registration
and recordkeeping
ATF believes
requirements
of our ind.ustry
members.
that
the requirements
we currently
impose on the
alcohol
beverage
industry
meet the requirements
of
ATF recommends
further
discussion
107-188.
P.L.
to minimize
duplication
of
between
our agencies
efforts
and unnecessary
redundancy
in regulating
the
alcohol
beverage
industry.
concerning
ATF's mission
I hope that
this
information
dnd
regulatory
functions
assists
you in your
Should
you require
regulations
writing
process.
further
assistance
on this
matter,
please
do not
I may be reached
at the ATF
hesitate
to contact
me.
Domestic
and International
Trade Division
(202)
9278100.
Sincerely
Domestic
Attachments
i3: Leslye
Fraser
and
Chief/
International
Yours,
Trade
Division
OMB
DEPARTMENT
BUREAU
PERSONNEL
TRADE
OR CORPORATE
OF ALCOHOL,
QUESTIONNAIRE
TOBACCO
AND
- ALCOHOL
SUPPLEMENTAL
TO BE USED (If any)
NAME
No. 1512-0034
(09/30/2002)
DATE
OFTHETREASURY
FIREARMS
AND TOBACCO
PRODUCTS
TO APPLICATION
FOR PERMIT FILED BY:
/BUSINESS
ADDREss
0F FIRM ph.
street,
and ZIP Code)
State
cffy,
/TELEPHONE
NuMBER
/
FULL NAME
LEGAL
Code)
OF APPLICANT
RESIDENCE
(No,
(Do no use /n/ha/s)
street,
ofy
HEIGHT
cl
MALE
0
FEMALE
OR TITLE
FATHER’S
NAME
State and ZIP
IN
USUALLY
TELEPHONE
WEIGHT
FT
POSITION
NAME
COLOR
HAIR
NUMBER
COLOR
EYES
OF
IF A MARRIED WOMAN, GIVE FULL
MAIDEN NAME & DATE OF MARRIAGE
USED
BUSINESS
ADDRESS
State and Z/P Code)
PLACE
OF
(No,
street,
or%
TELEPHONE
DATE OF BIRTH
OF BIRTH
SOCIAL
NUMBER
SECURITY
NO
LBS.
DESCRIPTION
OF DUTIES
OR RELATION
TO THE PROPOSED
OPERATION
I
MOTHER’S
MAIDEN
NAME
If the answer to any of the above questrons. 1 through 6 is “YES:’ grve full detarls under remarks or on a separate sheet, takrng care to
Convrcbons. arrests, or charqes for mmor traffic violatrons need not be reported
number the reply. to correspond with the questron
1
HAVE YOU EVER
2
HAVEYOU
3
HAVE YOU EVER
BEEN ARRESTED
4
HAVE YOU EVER
BEEN CONVICTED
5
HAVE YOU EVER BEEN COMPROMISED,
BY PAYMENT OF PENALTIES OR OTHERWISE.
RELATING TO INTERNAL
REVENUE
OR CUSTOMS
TAXATION OF DISTILLED
SPIRITS,
6
HAS DISAPPROVAL
EVER BEEN GIVEN TO ANY APPLICATION
OR NOTICE OF INTENTION
TO MANUFACTURE,
USE, STORE,
RECTIFY, BOTTLE, DISTRIBUTE,
SELL, IMPORT, OR TRANSPORT
ALCOHOL,
DENATURED
SPIRITS, DISTILLED
SPIRITS, BEER,
WINES, OR TOBACCO
PRODUCTS
FILED BY YOU OR ANY FIRM OR CORPORATION
OF WHICH YOU WERE PROPRIETOR
OR
A PARTNER,
OFFICER,
DIRECTOR,
PRINCIPAL
STOCKHOLDER,
OR RESPONSIBLE
EMPLOYEE’,
IF ANSWER
7
6
EVER
BEEN
BEEN
KNOWN
ARRESTED
BY ANY OTHER
NAME
FOR ANY VIOLATION
FOR VIOLATION
IS “YES.” STATE NAME
WHICH
ARE YOU A CITIZEN
OF THE UNITED
a
IF NATURALIZED,
GIVE DATE AND LOCATION
b
IF NOT A CITIZEN,
GIVE CURRENT
STATES
IF THE ANSWER
WHERE
CITIZENSHIP
IS “YES,” GIVE THE FOLLOWING
PERMIT
NUMBER,
b
PERIOD
COVERED
d
IF DISCONTINUED,
LAW
FEDERAL
OR MISDEMEANOR
APPLICATION
abases)?
O R STATE
UNDER
WAS FILED
NATURALIZATION
TO LICIUOR
AND
FEDERAL
ORTOBACCO
PRODUCTS?
OR STATE LAW-’
ANY VIOLATION
OF ANY FEDERAL LAW
WINES, BEER OR TOBACCO
PRODUCTS”
REASONS
PAPERS
FOR DISAPPROVAL
WERE
ISSUED
STATUS
WITH A PARTNERSHIP,
FIRM OR CORPORATION
EVER BEEN CONNECTED
TO MANUFACTURE,
USE, STORE, RECTIFY, BOTTLE, DISTRIBUTE,
SELL,
ALCOHOL,
DENATURED
SPIRITS, DISTILLED
SPIRITS, BEER, WINES, OR
AS APPLICABLE
IF KNOWN
c
NAME AND ADDRESS
WHEN
e
IF REVOKED, WAS SETTLEMENT
MADE OF CIVIL
INCURRED
THEREUNDER?
IF “YES,” WHEN?
&WHY’,
IF NO LIABILITIES.
9
RELATING
OR STATE LAW7
OF AMERICA?
HAVE YOU AS AN INDIVIDUAL
OR IN CONNECTION
WITH A FEDERAL
PERMIT OR APPROVED
NOTICE
DEAL IN. IMPORT OR TRANSPORT
OR TRANSPORT
TOBACCO
PRODUCTS’,
a
mcknames,
FEDERAL
OF ANY OTHER
OF ANY FELONY
UNDER
(Include
OF ANY
UNDER
WHICH
PERMIT
WAS ISSUED
LIABILITIES
SO STATE.
HAVE YOU EVER BEEN OR ARE YOU NOW EMPLOYED
BY ANY PERSON, FIRM, OR CORPORATION
MANUFACTURING.
OR
EXPORTING
TAX-EXEMPT,
TOBACCO
PRODUCTS,
PRODUCING,
STORING,
RECTIFYING,
BOTTLING,
SELLING,
IMPORTING,
OR DEALING
IN DISTILLED
SPIRITS, WINES, BEER, ALCOHOL,
OR DENATURED
SPIRITS, USING OR DISTRIBUTING
DENATURED SPIRITS, OR USING (OTHER THAN FOR PERSONAL
USE) DISTILLED
SPIRITS OR ALCOHOL?
IF THE ANSWER
a
WHEN
ATF F 5000.9
IS “YES,” GIVE THE FOLLOWING
EMPLOYED
(7-83)
b
IN WHAT CAPACITY
c
NAME
AND ADDRESS
//
OF PERSON,
FIRM,
OR CORPORATION
1
YES
I
NO
10
PERIOD
FROM
EMPLOYMENT
FOR PAST IO YEARS
POSITION
(Include
TO
NAME AND ADDRESS
OF EMPLOYER
(No, street, otv, county Stale, ZIP Code)
nature, penods, and addresses
of self-empioymentj
I
11
NAMES
RENCE,
AND ADDRESSES
(No, street, oty county,
AS TO YOUR CHARACTER
AND BUSINESS
CHARACTER/BUSINESS
CHARACTER/BUSINESS
q
YES
q
TELEPHONE
NUMBER
TELEPHONE
NUMBER
TELEPHONE
NUMBER
TELEPHONE
NUMBER
~TELEPHONE
I
NUMBER
TELEPHONE
NUMBER
TELEPHONE
NUMBER
REFE-
REFERENCE
REFERENCE
CHARACTER/BUSINESS
12 ARE YOU RATED
State, and ZIP Code) OF FIVE REFERENCES,
INCLUDING
AT LEAST ONE BANK
(Do not fnclude relabves or employers hsted ,n /fern 10 )
RESPONSIBILITY
-
REFERENCE
BY ANY
NO
13
COMMERCIAL
IF ANSWER
RESIDENCES
CREDIT
IS -YES” GIVE
REPORTING
NAME
TELEPHONE
AGENCY”
AND ADDRESS
FOR PAST TEN YEARS
NUMBER
(GM
OF AGENCY
street
address,
AND DETAILS
oty, county
OF RATING
State and ZIP Code)
PERIOD
FROM
TO
ADDRESS
ATF F 5000.9
(7-83)
14
OF YOUR
INVESTMENT
IN THE BUSINESS
INVESTMENTS
a
AMOUNT
TO DATE
b
SOURCE OF FUNDS INVESTED
(e g , personal savings, loans, ek : give name
name and address of lender lnclud,ng account number, rf appkable)
Under the penaltles of perjury, I declare that this statement, mcludlng
best of my knowledge and belief, IS true, correct, and complete
SIGNATURE
REMARKS
the documents
Jb
and address
submltted
of institut/on
m support
thereof,
In which funds are on deposit
has been examined
(Continue
on reverse
Information
or
by me and, to the
1DATE
OF APPLICANT
or on a separate
sheet, if necessary}
PRIVACY
The following
(If any)
IS provided
pursuant
to Sectton
ACT
STATEMENT
3 and 7(b) of the Privacy
Act of 1974 (5 U S C §552a(e)(3))
1
AUTHORITY.
SoIlcitatIon of this mformatton IS made pursuant to the followmg statutes
26 U SC
551 l(3). 5712. and 27 U S C 9204(c)
Disclosure of this mformatlon
by an applicant IS mandatory
busmesses
regulated pursuant to the above described statutes
2
PURPOSE.
To enable ATF to determme
regulated by ATF
3
ROUTINE USES. The InformatIon will be used by ATF to make the determmatjons
set forth in paragraph 2 In addltlon, the mformatlon may be dlsclosed to other Federal, State, foreign and local law enforcement
and regulatory agency personnel to verify mformatlon on the form where such dlsclosure is not prohIbIted by law The informatlon may further be disclosed to the Justlce Department
if It appears that the furnishing of false informatlon may constitute a violation of Federal law Fmally. the Information may be disclosed to members of the public In order to verify the informatlon on
the form where such disclosure
IS not prohibIted by law
4
EFFECTS
OF NOT SUPPLYING
INFORMATION
REQUESTED.
Failure to provide complete mformatlon may not prevent ATF from making an
informed judgment regarding the ellglblltty, suttabillty and/or qualification
of the applicant
This may result In either a delay tn the approval of an applicatlon or Its disapproval
5
DISCLOSURE
OF SOCIAL SECURITY
NUMBER.
above, ATF is authorized to soliclt th1.s mformabon
the ellglblllty.
suitabIlity.
with the Paperwork
and tobacco permit
qualificattons
of an applicant
who proposes
Disclosure of the tndlvldual social security number IS voluntary
The number may be used to verify the individual’s identity,
PAPERWORK
This request is In accordance
eligible to receive an alcohol
and/or
@5171(b),
5271(b), 5356. 5401(a). 5502(b),
If the applicant wishes to engage m any of the
REDUCTION
ACT
to engage
Pursuant
In a busmess
to the statutes
NOTICE
Reduction Act of 1995 The Information collection IS used by ATF to determine
The Information IS mandatory
(26 IJ S.C. 5712, 27 tJ S C 204).
if an applicant
is
The estimated average burden associated
with this collectton of mformatlon
IS 2 hours per respondent or recordkeeper,
dependmg on Individual
ctrcumstances
Comments
concerning
the accuracy of this burden estimate and suggestions
for reducing this burden should be addressed to
Reports Management
Officer, Document
Services Branch, Bureau of Alcohol, Tobacco and FIrearms, Washington.
DC 20226
An agency may not conduct
control number
or sponsor,
and a person
IS not required
to respond
to, a collectlon
of informatlon
unless
It displays
a currently
valid OMB
----
--..-OMB No. 1612407S
-.
(0413012003)
DEPARTMENT OFTHETREASURY
BUREAU
OFALCOHOL,TOEACCO
AND FIREARMS
POWER OF ATTORNEY
(Please
1.
PRINCIPAL
lnditidua!)
(Name
of Partnership,
3.
ADDRESS
(Number,
4.
TAXPAYER IDENTIFICATION
NUMBER
Nurnbec SO&/ S8curffy Number)
6.
NAME OF APPOINTED
7.
ADDRESS
9.
The above named
(Number,
CorporatlOn,
read Instructions
A#sc~St/cn,
on bade betore completing
Eatate or 2.
BUSINESS
lb/s tom)
IN WHICH
ENGAGED
Sfreet, Ctfy, Stale, end ZIP Cede)
5.
(fmp/oyw/denMicat/on
PERMIT
NUMBER
(//eppNceb/ej
ATTORNEY
Slreet,
principal,
Ciry StaM, and ZIP Code)
engaged
In me business
shown, has appoInted
the above-named
attorney
to: (See /nslrucfion
2)
(a) Execute for him all appllcatlons,
twtlces. bonda, tax returns, and other Instruments. claims, offers In compromise.
letters, writings, and papars. end to
act (or him In deallna with the Bureau of Alcohol. Tobacco and FLrearms In connection with matters relating lo the lws and regulations admlnlaterad
by It. The prlnclpal aumorlzos me attorney named abwe to recaive on his behalf any and all notIces. pap&,
and letters from the Bureau of Alcohol.
Tobacco and Flrearms In c~nectk~
wlm all such matters, and grants hlm full power and euthorlty IO dc all that Is eesentlal In and about the pw@a.
as duly es the prindpal could do If peracnally present. tilh lull power ol substltuticn
and r-non.
The prlnclpal hereby ratlfles and confirms all
that the attorney shall latiully do or cause to be by virtue of thls appdntmenl.
(b)
9.
The powar Is to apply to the ldlcwmg.
(/laut/w/fy
/s restrtcted to d parf~cukr tacfory, ptanl, premises, ekz., g&w name es: Dlshfled Sptrifs Ptanl.
Tobacco Prcducb Factory. Tobacco Ewpcrl Warehouse, stc, and eddms?~ and number
oc If B Whalesale Liquor Lkx7tec g/w pwmd number)
10. SIGNATURE
OF APPOINTED
11 SIGNATURE
IFPRINCIPAL
12. SIGNATURE
IF PRINCIPAL
Under penalties
01 me principal.
I
I
I
d perjury
ATTORNEY
I.
IS INDIVIDUAL
IS PARTNERSHIP,
I declare
EXECUTION
olPrJnc@a/)
(Slgnalure
ESTATE,
(See lnstruclion
CORPORATION.
that I have the aulhorlly
3)
DATE
OR ASSOCIATION
to execute this power of attorney
Signature
Title
Date
Signature
Tltte
Data
Slgnature
Tltl8
Data
Slp8lUr8
Tltte
Date
on behalf
14. SEAL OF CORPORATION
OR
ASSOCIATION
(/f there Is no see/,
enech a certllled cow da resdutbn
_
duty passed by the board 01 drrecbn
eumorlzlrlg
the execution ol ma power ol
aftomey and check Ihe box shown
bel0m)
q
I
13 ATTESTATION
ATF F 500&U
BY SECRETARY
(Z-95)
PREVIOUS
OF CORPORATION
EDITtONS
OR ASSOCIATION
ARE OBSCLETE
I
No Seal
15&.>CKNOWLEDGMENT
15.
ACKNOWLEGGMENT,
--___
WITNESSING,
;I=
OR DECLARATION
WVi~%i~~
(Con~p!ele
154, 159, oi f5Cj
.-._.
&TE
.RCCEIVED
FOR i-ILING
AFSERVED
DISTRICT
FOR THE BUREAU
OF “-ALCOHOL.
/RECEIVED
BY
TOBACCO-- AND..-___.
FIREARMS
(Sr~n~ture 8”d 7ffl.l)
___
--~~
I
INSTRUCTIONS
4.
I” ~UCIILS& ~“IJSS olhorwsa
I ‘LING Thts !orm shall bo comp’et;d
reowred. and submlXed to the Owr~ct I> rec:or of the d st”ct in whlr.h
th, business or establtshmen~ IS localad
The o:igm& with any attachmsnts will be ratamed by the Our!ot Duector, and ail other copms will
be returned lo the pnnctpal. After recwpt 01 these cop@s from the
Oltnct Dwctor. submll two copwxs to any other ATF office in which the
appimd
an0tnRy
WIII repsent
the prI~~pai
These ATF offIces WI’
reluln one cow for tllmg and return the other cow lo the principal
If
the power of attorney IS apphcable to more than one estab+shment of
business. additwal
copies must be submitted tar each The add!Oa”al
copes wll be Illed m the same manner as when the power of attorwy
relales lo oniy 0”~ establishment
or busmess
Copies reproduced by
photographk
process “eed not be certified as copws of the wlgwl
llopwts Management Olt~cor, Document Snrwces Branch.
Alcohol. Tobwco and Firearms. Washlnoto?, DC 20226
Buieau
A” agency moy not conduct or sponsor and 0 person 15 701 reqwred to
respond to. a coIIoc!Ion 01 !nformation unless it displays R currently yaill!
OMB control number
ATF FSOW.8
^ ._,._
.
c!
(‘2-95)
OMBNo.1512-0188(~AOR004)
DEPARTMENT
BUREAU
OF THE TREASURY
OF ALCOHOL
SIGNING AUTHORITY
TOBACCO
AND FIREARMS
FOR CORPORATE
OFFICIALS
INSTRUCTlONS
Prepare and submtt to the Chief. Techmcal Serwes. Bureau of Alcohol, Tobacco and Firearms. m dupltcale
Each copy must be stgned in Ink by a Corporate
ofk~al and be embossed with the corporate seal This lorm may be used to list me corporate otftuals.or employees (If any). who are atnhonzed by the
arbcles of mcorporabon. the bylaws, or the board of dwectors in adopted resolut~ons,or mobons. to act on behalt of me corporaboo or to ugn its name. If the
authorltabon
to sign IS granted by position tltie, ratherthan to speclftc indtwduala by name. a new authorlzabon wll not be needed each bme a Change of
incumbent occurs WHERE THE AUTHORIZATION
IS NOT GRANTED BY THE ARTICLES OF INCORPORATION.
THE BYLAWS. OR ACTION BY THE
BOARD OF DIRECTORS.
ATF F 5000.8. POWER OF ATTORNEY, MUST BE SUBMITTED.
PAPERWORK
l-w request IS IP. accordance m m Papenvork Reduchon Act of 1995
mcitwduals are signing documents.
This rn(ormabon is voluntary
REDUCTION
This mformabon
ACT NOTICE
collection
IS used by ATF to ensure that only duly authtonzed
The estimated average burden associated with this collechon of lnformabon IS .25 hours per respondent or recordkeeper dependmg on mdwldual CIrcumstances. Comments concomIng the accuracy
of this burden esbmate and suggestions for reducmg this burden estimate and suggesbons
for reducing ttns
burden should be addressed to Reports Management Offuer. Document Serwcess Branch, Bureau of Alcohol. Tobacco and Firearms. Washqton.
DC
20226.
An agency
number.
may not corxluct
NAME AND COMPLETE
or sponsor, and a persMI is n-3 required to respond to, a collecbon
ADDRESS
ot lnformabon
OF CORPORATION
unless it displays
COMPLETE
cl
a currently valid OMB control
APPLICABLE
INFORMATION
NEWAPPLICANT
PERMITHOLDER
cl
PERMIT NO.
DATE MEETING
BOARD MEETING
cl
DIRECTORS
cl
TRUSTEES
G
MANAGERS
THE FOLLOWING
CORPORATE
OFFICIALS. EMPLOYEES,
APPOINT PERSONS AUTHORIZED
TO SIGN, DOCUMENTS
BUREAU OF ALCOHOL. TOBACCO AND FIREARMS.
I certify that this Is true and complete
moating ofthe board.
SIGNATURE
and
cl
OR INCUMBENTS
OF THE OFFICES LISTED ARE AUTHORIZED
TO SIGN. OR TO
(Speufy type of doamenls)
SUBMITTED ON THE CORPORATION’S
BEHALF TO THE
that the above authorlzalion
wae granted
DATE
TITLE
I
ATFF5100.1
(11-97)
HELD
GOVERNORS
at the cited
CORPORATE
SEAL
OMBNo.
DEPARTMENT
OF ME
1512-0036(~~1~~)
TREASURY
BUREAUOFALCOHOL,TOBACCOANDRREARMS
AUTHORIZATION
T O FURNISH FINANCIAL INFORMATION
AND
CERTIFICATE O F COMPLIANCE
(Right
SECTION
A: CUSTOMER
to Financial
AUTHORIZATION
1,
authonre the following financial insQtUtton todisclose
Bureau of Alcohol, Tobacco and FIrearms.
NAME OF FINANCIAL
s
INSTITUTION
AND
the Cnanclal records
PERSON
TO
CONTACT
Privecy
Act of 1976)
(12 U.S.C. 3404) TO BE COMPLETED
BY CUSTOMER
having read the explanation of my nghts on the reverse of this form. hereby
speclfted below and any and all Information pertainmg to those financial records to the
(IF KNOWN)
----___-.
STREET
1 CITY,
ADDRESS
CHECKING
SAVINGS
ACCOUNT
ACCOUNT
NUMBER
:
STATE
AND
ZIP
CODE
--~~~~~~~-~~~~.
._~~~~.._.
AND NAME ON ACCOUNT
NUMBER
AND
NAME
ON
ACCOUNT
LOAN NUMBER
AND NAME(S)
APPEARING
--
OTHER (SPECIFY)
PUF?POSE FOR WHICH
DISCLOSURE
ON LOAN
~-~-.
IS NECESSARY
.-___
~dthatth#sauthonratron
maybe
revoked bymeInwnting&ztany
valid for no more than three (3) months from the date of wgnature.
SIGNATURE OF CUSTOMER
ADDRESS
t,mebeforemyrecords,
asdescnbedabove.
aredjsclosedendthatthlsaulhonzatlon
1 DATE
OF CUSTOMER
NAME OF FINANCIAL
INSTITUTION
SECTION 6: CERTtFlCATE
OFFICIAL AND TITLE
OF COMPUANCE
BY ATF OFFICER
(12 U.S.C. 3403(b))
DATE OF REQUEST
I hereby certify that the applicable provls8ons of the Right to Fmancml Privacy Act of 1978.12 USC 3401-3422, have been complted with and the good faith
rellanceuponth~scerttficaterelievesyourlnstrtutionanditsemployeesandagentsof
anyposstblel~ab~l~tytothecustomerlnconnechon
w~ththedkcfos~reof
thesefinanual
records
__.
.~..-.-__-ADDRESS
SIGNATURE OF ATF OFFICER
I
NAME AN0 TITLE OF ATF OFFICER
ATf F5030.6
(12-67)
PREVIOUS
(TELEPHONENUMBER(lncludingAraaCode)
tDlTlONS
ARt
OBSULt
IE
IS
INSTRUCTIONS
If you
have
contact
your
any
questtons
nearest
about
ATF
your
rights
under
thus law
1
Section
A should
be completed
by the
customer
2
Sectton
B should
be completed
by the
ATF
3.
Dtstributron
a
or about
how
Ongrnal
b
Second
c
Thtrd
(wtth
copy
copy
Sectton
(with
(without
in tnplrcate
officer
B completed)
Section
RIGHT
TO
wtth
to the
OF
FINANCIAL
YOUR
of your
financial
records,
you
rnay
RECORDS
CONSENT
Without your consent, a Federal agency that wants to see your
financial records may do so ordmanly only by means of a lawful
subpoena, summons, formal wntten request, or search warrant for that
purpose
Generally, the Federal agency must grve you advance notrce of
its request for your records explatnrng why the tnfon-natron IS berng
sought and tellmg you how to object rn court The Federal agency
must also send you copres of court documents to be prepared by you
with mstructions for tillrng them out Whrle these procedures wrll be
kept as simple as possrble. you may want to consult wrth an attorney
before making a challenge to a Federal agency’s request
PAPERWORK
check
institutron
the
report
of inspectron
customer
RIGHTS
PRIVACY
You may be asked to consent to make your financral records
avarlable to the Government
You may withhotd your consent, and
your consent IS not requtred as a condrtlon of doing bustness wrth any
financial rnstrtutton If you grve your consent, It can be revoked in
writing at any time before your records are dtsclosed
Furthermore,
any consent you grve IS effectlve for only three months, and your
financtal tnstrtutron must keep a record of the Instances In whrch It
discloses your financial mformatron
WITHOUT
release
THE
Federal law protects
the privacy of your financial
records
Before banks, savmgs and loan associations,
credit unrons, credrt
care Issuers or other finance1 instrtutrons may gave finanaal mformatton about you to a Federal agency, certarn procedures must be
followed
-
record
CUSTOMER
UNDER
TO FINANCIAL
to the
to ATF
financial
fmancial
filed
B completed)
returned
the
to the
B completed)
Sectron
and
conductrng
STATEMENT
CONSENT
to consent
office
REDUCTION
ACT
OF
1978
EXCEPTIONS
In some ctrcumstances,
a Federal agency may obtain financial
informatron about you without advance notice or your consent
In
most of these cases, the Federal agency will be required to go to court
to get permisston to obtarn your records without givrng you nottce
beforehand
In these Instances, the court will make the Government
show that Its mvesttgatron and request for your records are proper
When the reason for the delay of notice no longer exists,
you WIII usually be notfied that your records were obtained.
Generally,
the Internal
Revenues
Servrce will continue
to
get records pursuant to Its extstrng procedures
authonzed
by the
Internal Revenue Code rather than under the Right to Fmandal Privacy
Act
TRANSFER
OF
INFORMATION
Generally,
a Federal
agency
whrch obtains
your fmancial
records IS prohtbtted
from transferring
them to another
Federal
agency unless It certifies rn wntrng that the transfer IS proper and
sends a notrce to you that your records have been sent to another
agew
PENALTIES
If a Federal agency or financlal rnsbtution violates the Right
to Ftnanctal Privacy Act, you may sue for damages or to seek compkance wtth the law If you win, you may be repaid your attorneys
fees and cc&.
ACT
Thts request IS in accordance wtth the Paperwork Reducton Act of 1960 This Information
to recarve an alcohol or tobacco permtt The rnformatron IS requrred to obtain a beneft.
NOTICE
collectron
issued by ATF to determtne
if the applicant
is etrgrble
ATF F 5030 6 (1 Z-67
OMB NO. 1512-0472
DEPARTMENT
BUREAU
SPECIAL
(Please
1 E
MPLOYER
iflsbucbons)
IDENTIFICATION
NUMBER
( 09/30/2002)
OF THE TREASURY
OF ALCOHOL,
TOBACCO
AND FIREARMS
TAX REGISTRATION
AND RETURN
ALCOHOL AND TOBACCO
Read Instructions
on Back
SECTION I - TAXPAYER
2
(Regurredsee
Carefully Before Completing
IDENTIFYING
INFORMATION
BUSINESS
(
)
TELEPHONE
This Form)
NUMBER
FOR ATF USE ONLY
I
3 N
AME (Lasf, First, Mddle)
4 T
RADE NAME
CORPORATE
or
NAME
T
(If Corporabon)
tiA
FP
5 M
6C
AILING ADDRESS
(Street address
or P 0. box number)
ITY
I
T
ZIP CODE
STATE
9 TAX PERIOD
ACTUAL
7 P
HYSICAL
8C
ITY
ADDRESS
OF PRINCIPAL
LOCATION
PLACE
(IF DIFFERENT
OF BUSINESS
THAN ABOVE)
COVERING
FROM
(Show street address)
(mmlddiyy)
TO June 30.
ZIP CODE
STATE
w
SECTION
II - TAX COMPUTATION
MONTHLY
TAX CLASS DESCRIPTION
(FOR ITEMS MARKED’, SEE INSTRUCTIONS)
(a)
(b)
$250
Lrquors (D&/led
sprnts, wme or beer)
$20 83 ;I,
RETAIL
DEALER
Beer only
$20 83 ‘i?
250
Lrquors (Dtstrlled Spmts, Wine or Beer) - at large
$20 83 ‘/?
250
Beer only - at large
$20 83 ‘I,
250
WHOLESALE
Drstrlled spmts, wme or beer
$41 66 211
500
ni=AI FE)
I Beer onlv
I 541lifi~1.
I
500
I
1000
Regular rate
$83 33 ‘I,
BREWER
500
$41 66 *1?
REDUCED rate*
500
NONBEVERAGE
DRAWBACK
CLAIMANT
250
User of specially denatured alcohol
$20 83 ‘I?
INDUSTRIAL
250
$20 83 ‘I?
Dealer In specrally denatured alcohol
ALCOHOL
250
User of tax-free alcohol
$20 83 ‘11
1000
Proprietor of alcohol fuel plant
$83 33 ‘il
ALCOHOL
$41 66 */?
500
Propnetor of alcohol fuel plant - REDUCED’
PRODUCERS
1000
Proprietor of drstrlled spmts plant
$83 33 ‘I?
500
Propnetor of drstrlled spmts plant - REDUCED’
$41 66 21,
1000
$83 33 ‘i,
Proprietor of bonded wine cellar
500
1
Propnetor of bonded wane cellar - REDUCED’
$41 66 211
1000
(
Proprietor of bonded wine warehouse
$83 33 ‘I,
$41 66 2/?
500
1
Propnetor of bonded wme warehouse - REDUCED’
Propnetor of taxpard wane bottling house
1000
1
$83 33 ‘I?
Proprietor of taxpard wine bottling house - REDUCED*
500
1
$41 66 */,
$83 33 ‘I?
1000
1
Manufacturer
of tobacco products
TOBACCO
Manufacturer of tobacco products - REDUCED’
500
1
$41 66 ?I1
PRODUCTS
Manufacturer
of ctgarette papers and tubes
1000
1
$83 33 ‘ix
Manufacturer of cigarette papers and tubes - REDUCED’
$41 66 21?
500
1
1000
1
Propnetor of export warehouse
$83 33 ‘I,
Propnetor of export warehouse - REDUCED
500
1
$41 66 Zil
MAKE CHECK OR MONEY ORDER PAYABLE TO “BUREAU OF ALCOHOL, TOBACCO AND FIREARMS’, WRITE YOUR EMPLOYER t TOTAL
IDENTIFICATION NUMBER ON THE CHECK AND SEND IT WlTH THE RETURN TO BUREAU OF ATF, P.O. BOX 371962, PITTSBURGH 0 00
PA 15250.7962.
VL,
>LLI
__
\
11
12
15
16
31
I
t-sii*
51
55
56
57
58
59’
81
86’
82
87*
83
88*
84
89’
91
95’
92
96’
93
97’
TAX DUE $
Under penalbes of pejury, I declare that the statements In thus retumlrqstrabon are tme and correct to the best of my knowledge and belief; that thus return/
reglstrabon applres only to the specified busmess and location OT,where the retumkgrstrabor IS for more ihan one Ition,
It applies only to the busrnesses at the lxabons speofied on the
attached list Note Vldatron of Title 26, Unrted States Code 7206, is punrshable upon conv~cbonby a fine of not more than $100,000 ($500,000 in fhe case of a corprabon) M impnsonment
for not more than 3 years cr both wtth the costs of prosecution added thereto
SIGNATURE
ATF F 5630.5 (10-99) PREVIOUS
TITLE
EDITIONS
ARE OBSOLETE
DATE
SECTION
IO OWNERSHIP
(Check
One Box On/y)
11 OWNERSHIP
FULL NAME
III - BUSINESS
REGISTRATION
INFORMATION
0
RESPONSIBILITY
INDIVIDUAL
OWNER
0
PARTNERSHIP
(Read rnstructton sheet, use a separate
ADDRESS
0
CORPORATION
sheet of paper If addttlonal
0
OTHER
space IS needed )
POSITION
FULL NAME
ADDRESS
POSITION
FULL NAME
ADDRESS
POSITION
FULL NAME
ADDRESS
POSITION
FULL NAME
ADDRESS
POSITION
12.
u
GROSS
13
u
NEW BUSINESS (NOTE: RETAILERSAND
BEVERAGE SALES BEGAN, PRODUCERS,
BUSINESS COMMENCED)
14
q
EXISTING
u
(a)
RECEIPTS
less than $500,00O’(See
BUSINESS
WITH CHANGE
NAME/TRADE
NAME
uxtrucbons
forreduced
rate taxpayers
(Soecifyj
on the attached
,nstrlcbon
sheet)
DATE OF CHANGE
WHOLESALERSSHOWDATEALCOHOLIC
MANUFACTURERS
AND USERS SHOW DATE
(mm, dd. yy)
IN
@d/cafe)
DATE OF CHANGE
(mm, dd, yy)
DATE OF CHANGE
(mm. dd, yyj
DATE OF CHANGE
(mm, dd. yy)
DATE OF CHANGE
(mm, dd, yy)
I
0
(b)
ADDRESS
u
(c)
OWNERSHIP
0
(d)
EMPLOYER
(OLD
0
15
0
(e)
(Indjcate)
(Indicate)
IDENTIFICATION
BUSINESS TELEPHONE
)
(
DISCONTINUED
NUMBER
NEW
1
NUMBER
DATE BUSINESS
BUSINESS
PAPERWORK
REDUCTION
This tnfonnahon IS used to ensure compliance by taxpayers of P L 100-647, Technical
States ATF uses the InformatIon to determIne and collect the right amount of tax
DISCONTINUED
(mm, dd. yy)
ACT NOTICE
Correcttons
Act of 1988, and the Internal Revenue
Laws of the Unlted
The eshmated average burden assoaated wtth this collectron of lnformatron IS 8 hours per respondent or recordkeeper, depending on tndtvldual arcumstances
Comments concemtng the accuracy of this burden estimate and suggestions for reductng this burden should be addressed to Reports Management
Officer, Document Servtces Branch, Bureau of Alcohol. Tobacco and Ftrearms. Washington, D C 20226
An agency may not conduct or sponsor, and a person IS not required to respond to, a collectton of information
number.
(SEE ATTACHED
INSTRUCTION
unless It displays a currently valid OMB control
SHEET)
ATF F 5630.5 (10-99)
INSTRUCTION
SHEET
ATF FORM 5630.5, SPECIAL TAX REGISTRATION
ALCOHOL
AND TOBACCO
GENERAL
INSTRUCTIONS
AND RETURN
SECTlON
If you are engaged in one or more of the alcohol or tobacco actlvlties listed
on thts form, you are required to file this form and pay special occupational
tax before begInning business If you are engaged in NFA firearms related
actlvltles do not file thts form You must file ATF F 5630 7 You may tile one
return to cover several locations or several types of activity However, you
must submtt a separate return for each tax period The special occupatronal tax penod runs from July 1 through June 30 and payment IS due
annually by July 1 (except ,n the case ofnonbeverage
drawback clajmanfs
who must pay speoal tax before r%il,ngc/aims) If you do not pay on a timely
basis, Interest will be charged and penalties may be incurred
Ill - BUSINESS
REGISTRATION
Please complete the ownershlp information in Section III Supply the informatlon specified in Item 11 for each indlvldual owner, partner or respon-sable
person For a corporation, partnership or association, a responsible
person IS anyone with the power to control the management pollctes or
buying or selling practrces pertarnlng to alcohol or tobacco For a corporatlon,assoaatlon
or simtlar organization, It also means any person owning
10 percent or more of the outstanding stock in the business
CHANGES
IN OPERATIONS
As evidence of tax payment, you WIII be Issued a Spectal Tax Stamp.
ATF F 5630 6A. for each location and/or business.
If there IS a change of address or locatIon. ATF F 5630 5 must be completed
and submitted withtn 30 days of the change (90 days for nonbeverage
drawback c/a/man&) Return your Special Tax Stamp, ATF F 5630 6A.
along with the completed ATF F 5630 5 to Bureau of ATF, 8002 Federal
Oftice Building, 550 Matn Street, Clncinnatl. OH 45202-3263 and an
amended ATF F 5630 6A WIII be Issued All taxpayers except retall dealers
must also contact the ATF National Revenue Center In order to amend their
license or permit or to obtain a new one
The special tax rates llsted on this form became effective January 1, 1988
If you were engaged in an alcohol or tobacco related activity pnor to this
date and did not pay special occupational tax, please contact the ATF
National Revenue Center for asststance.
If special taxpayers do not register these changes withln the appropriate
time frames, additronal tax and Interest will be charged and penalttes may
be Incurred For a change in ownershlp or control of an activity consult the
ATF National Revenue Center before begInnIng the acttvity
If you engage in a taxable actlvlty at more than one location. attach to your
return a sheet showing your name, trade name, address and employer
ldenttficatron number and the complete street addresses of all addItIonal
locations
SECTION
I - TAXPAYER
IDENTIFYING
INFORMATlON
Complete Section I Taxpayer ldentifylng Infonatlon.
as specltied on the
form Enter the tax penod covered by the return in the space provided
Your return must contain a valid EMPLOYER IDENTIFICATION
NUMBER
(EIN) The EIN ts a unique number for business entities issued by the
Internal Revenue Service (IRS) You must have an EIN whether you are
an individual ownership,
partnership,
corporation,
or agency of the
government.
If you do not have an EIN, contact your loal IRS office
lmmedrately to obtarn one While ATF may asslgn a temporary Identtficatlon number (begInnIng with XX) to allow inttial processing of a return which
lacks an EIN. a tax stamp will not be issued until you have submitted
a
valid EIN. Do not delay submIssion of your return and payment past the
due date pendlng receipt of your EIN If you h3ve not received a number by
the time you file ths return, write “numberappkedfor”in
the space for the
number Submit your EIN by separate correspondence
after receipt from
the IRS
SECTION
II -TAX
COMPUTATION
To complete Section II, enter the number of locatIons in Col (d) on the
appropnate Ilne(s) and multiply by the tax rate, Col (c) Insert the tax due
In Cot (e) If you begin operations (except for nonbeverage drawback
operabons) after the month of July, then you are responsrble for paying a
prorated amount for the portions of the year you are in business To
compute your taxes, multiply the monthly rate, Col (b). by the number of
months, treating parts of months as whole months, from the date you
commenced operations through June 30 (For example, ffyou commenced
operabons on March 14, you would m&p/y by 4 ) Compute the taxes due
for each class and enter the total amount due in the block ‘Total Tax Due”
INSTRUCTlONS
FOR REDUCED
RATE TAXPAYERS
The reduced rates for certatn taxpayer classes, indicated wfth an asterisk
(‘) In Sectlon II, apply only to those taxpayers whose total gross receipts for
your most recent income tax year are less than $500,000 (not@
receipts
relabng lo the act&y subject to spenal occupabonal tax) However, I f you
are a member of a controlled group as defined in section 5061(e)(3) of the
Internal Revenue Code, you are not eligible for this reduced rate unless the
total gross receipts for the entire group are less than $500,000 If your
business IS beginning an activity subject to special tax for the first time. you
may qualify for a reduced rate in your initial tax year if your gross receipts
for the bustness (or the enbre control group, If a member of a control group)
were under $500,000 the previous year If you are eltglble for the reduced
rate. check Item 12 !n Section III and compute your tax using the reduced
rate In Setion II
DEFINITION
A RETAIL DEALER (tax c/ass codes II, 12, 15, or 16) IS anyone who sells
or offers for sale, alcoholic beverages to any person other than a dealer
Examples of retailers are package stores, restaurants. bars, pnvate clubs,
fraternal organlzattons, grocery stores or supermarkets which sell such
beverages
A RETAIL DEALER AT LARGE IS one who moves his actlvlty from place to
place In different States, such as a circus or carntval
A WHOLESALE
DEALER (tax c/ass codes 37 or 32) IS anyone who sells or
offers for sale, alcoholic beverages to another dealer An IMPORTER IS
liable for tax as a wholesaler If he or she sells alcoholic beverage to other
dealers (wholesalers or fetal/e@
SIGNING
RETURN
This form must be slgned by the lndlvldual owner, a partner, or, in the case
of a corporahon, an Individual authonzed to sign for the corporation
MAILING
Please sign and date the
BUREAU OF ALCOHOL,
the Total Tax Due block,
PAYMENT TO BUREAU
7962
INSTRUCTIONS
return, make check or money order payable to
TOBACCO AND FIREARMS, for the amount In
and MAIL THE FORM ALONG WITH THE
OF ATF, P 0. Box 371962, Pittsburgh. PA 15250-
IF YOU NEED FURTHER ASSISTANCE
CONTACT ATF NATIONAL REVENUE CENTER
AT
I-800-937-8864
OR
513-684-2979
SEE IMPORTANT
TAXPAYER
REMINDER
ON THE BACK OF THIS PAGE1
ATF F 5630.5 (1 O-99)
TAXPAYER
REMINDER
This is an annual tax due before starting business and by July 1 each
year after that. After your initial payment of this tax, you should receive
a “renewal” registration
and return each year in the mail, prior to the due
date. However, if you do not receive a renewal form, you are still liable
for the tax and should contact the ATF National Revenue Center noted
in the instructions
to obtain a Special (Occupational)
Tax Registration
and Return.
Your canceled check may be used as evidence
receive your Special Tax Stamp from ATF.
of tax payment
until you
ATF F 5630.5 (10-99)
OMB
DEPARTMENT
BUREAU
FULL NAME AND PREMISES
TELEPHONE
NUMBER
State in which organized
2
MAILING
a
b
ADDRESS
AND FIREARMS
FEDERAL
ALCOHOL
ADDRESS
(
)
for Corporations
(/f d/fferent
and Llmited
from prem/ses
Liability
Companies
ADMINISTRATION
EMPLOYER IDENTIFICATION
NUMBER (EIN)
(Social Security number IS not acceptabiei
4
OPERATING
5
LABELING
NAME
TRADE
INTO THE UNITED
c ‘~~-- IMPORTING
;:I DISTILLED
SPIRITS
-~
Eli WINE
::, MALT BEVERAGES
d r
PURCHASING
FOR RESALE
:A DISTILLED
SPIRITS
.~, WINE
_: MALT BEVERAGES
WINE
b
8
c
NEW BUSINESS
Antlctpated start date
If any
AT WHOLESALE
beverages
so dtstllled
of predecessor
CHANGE IN CONTROL
(Actual or legal)
Submit Basic Permit(s) with this appkation
Date of Change ~~ _________ ~~~
OWNER INFORMATION
lhan 10% vot/ng stock
(&so/e
owner, a// genera/ parhes.
Each listed person must a/so furmsh
TITLE
LLC members/managers,
corporate
the informat,on ,n Item 9 )
%LoTffi
iFAPPllCAN?IS
ACTUALCYORL?GALLY
CONTR<~LEDBYPERSONS
SHEET INFORMATION
(as speofied
for /tern 9) FOR EACH PERSON
BUSINESSES
SHOULD INCLUDE THEIR EIN
COMPLETE
FULL GIVEN
FOR EACH PERSON
NAME
e
f
MALE
g
If any
NAME(S),
CHANGE IN OWNERSHIP
Date of Change _~~__ .__~-----_
Name, address and permit number(s)
.__
NAME
9
a
(DBA).
STATES
or while so engaged, sell, offer, or deliver for sale. contract to sell, or ship In interstate or foreign commerce the alcoholic
produced, rectlfled, blended or bottled, warehoused
and bottled, Imported or purchased for resale at wholesale
7 ~. REAsoN
FoR THE~APPCICATloN
~~~~~-. .___~~~~~~
a
ACT
3
(LLC)
address)
J DISTILLED SPIRITS PLANT
(BEVERAGE)
-~J DISTILLING
.~J WAREHOUSING
AND BOTTLING
DISTILLED
SPIRITS
i PROCESSING
(RECTIFYING)
DISTILLED
SPIRITS AND WINE
WINE PREMISES
~-1 BONDED
_
PRODUCING
AND BLENDING
.
BLENDING WINE
(0313112002)
OF THE TREASURY
OF ALCOHOL.TOBACCO
AmP~dLICATION FOR BASIC PERMIT UNDERTHE
1
NO. 1512-0089
RESIDENCE(S)
ATF F 5100.24
OTHER
LISTED
IN ITEM 8
~b DATE AND
!
BIRTH
---A.- -~~~~~
NAMES USED
(Ma/den
~ FEMALE,
OVER THE LAST
(4-99)
(Replaces
FIVE YEARS
ATF F 5170.4)
PLACE
SSCCKINTERST
I if applkab/eJ
OR BUSINESSES
OR BUSINESS
AND
OF
c
offfcers and directors,
INVESTMENT
IN
BUSINESS
(Item 6)
NO-~ IDENTIFIED
ABOVE,
STATE THE EXTENT AND
SoC!%‘oR
IDENTIFICATION
and shareholders
SOlRCEOFFUND
INVESTED
jsanngs, loans. gaff or soeofy oiheri
PROVIDE
MANNER
EMPLCNERT;j
NUMBER
I~~~~~_~ .“--~--
name,
mcknames.
etc)
wth more
ON A SEPARATE
OF THE CONTROL
..~
.__.~~
ARE YOU A U S CITIZEN”
YES
NO
~~~~~
a
FULL
GIVEN
b
NAME
DATE AND
BIRTH
PLACE
OF
c
SOCIAL SECURI-l-f Cf? EMFLOYER
IDENTIFICATION NUMBER
d
ARE YOU A U S CITIZEN3
YES
f
;..r?
--I
MALE
g RESIDENCE(S)
a
FULL
GIVEN
OTHER
NAMES
USED
(Ma/den
name,
DATE AND
BIRTH
PLACE
nIcknames,
-~
etc)
FEMALE
OVER THE LAST
FIVE YEARS
b
NAME
c
OF
SOCIAL SECURITY CR EMPCCXER
IDENTIFICATION NUMBER
d
ARE YOU A U S CITIZEN’,
NO
YES
f
i_i
MALE
E
OTHER
NA@<xEo(?&yden
name,
nicknames,
etc)
FEMALE
g
RESIDENCE(S)
a
FULL
GIVEN
OVER THE LAST
FIVE YEARS
b
NAME
DATE AND
BIRTH
PLACE
c
OF
SOCIAL SECLlR1l-f OR ENaLWER
IDENTIFICATION NUMBER
d. ARE YOU A U S CITIZEN7
1
f
MALE
--
-2
g RESIDENCE(S)
a. FULL
GIVEN
OTHER
NAM6S-bSEDm
(Ga,den~name,
mcknames,
YES
: -:
Imp-. NO
etc)
FEMALE
OVER THE LAST FIVE YEARS
b
NAME
DATE AND
BIRTH
PLACE
c
OF
SOCIAL SECURITY CR EMPLOYER
IDENlIFICAl7ON
NUMBER
d
ARE YOU A U S CITIZEN’,
NO
YES
e
_.._
,--j
g
10
NO
-f
MALE
OTHER
NAMES
USED
(Ma/den
name,
nxknames.
etc)
FEMALE
RESIDENCE(S)
OVER THE LAST
FIVE YEARS
HAS THE APPLICANT
OR ANY PERSON LISTED FOR ITEMS 8 OR 9 EVER BEEN DENIED A PERMIT.
LICENSE OR OTHER AUTHORIZATION TO ENGAGE
IN ANY BUSINESS
T3 MANUFACTURE.
DISTRIBUTE,
IMPORT,
SELL OR USE ALCOHOL
PRODUCTS
(beverage
or
nonbeverage)
BY ANY GOVERNMENT
AGENCY
(Federal,
State, local or foreign) OR HAD SUCH PERMIT.
LICENSE OR OTHER AUTHORIZATION
REVOKED,
SUSPENDED
OR OTHERWISE
TERMINATED?
i’
YES
State
..-i
~I-HASTHEAPPLICANT
OF ANY CRIME
Federal or State
--1
i ~ YES
State
details
of each event on a separate
0~
UNDER
law
details
sheet
NO
ANY PERSON
LISTED FOR ITEMS 8 OR 9 EVER BEEN ARRESTED
FOR, CHARGED
WITH. OR CONVICTED
FEDERAL,
STATE OR FOREIGN
LAWS other than traffic violations
or convIctIons
that are not felomes under
of each event on a separate
sheet
NO
ATF MAY REQUIRE
additional
InformatIon
to process
this application.
If you are applying for a basic permit to operate a dlstllled spmts plant
or bonded wine premises, you must also file addItIonal forms and InformatIon
required under the Internal Revenue Code
OPERATION
WITHOUT
A
PERMIT.
Cnmlnal and admlntstratlve
actions may be taken agamst persons engaged In a business llsted In Item 6 of this form if It IS not conducted
pursuant to an FAA Act basic permit
APPLICANT’S
AFFIRMATION
Under penaltles of perjury, I declare that I have examined this application,
mcludlng accompanymg
statements,
and
The applicant WIII immediately
notify the ATF offlclal with whom this
to the best of my knowledge
and belief, It IS true, correct and complete
application
IS flied of any change In ownershlp.
management,
or control of the applicant (In the case of a corporat/on.
any change m the officers.
The busmess for which this application
IS made does not violate the law
d/rectors,
or persons holding 10 percent or more of the corporate
stock)
of the State In which the business WIII be conducted
In addltlon. If this application
IS approved,
the applicant WIII conduct operations within a
reasonable
period of time and malntaln such operations
in conformity
with Federal law
12
APPLICANT’S
SIGNATGR?
(Sole owner, partner, corporate
officer, LLC member or manager, or rf designated
agent, submit
ATF F 5000 6)
15
E-MAIL
(INTERNET)
ADDRESS
13 TITLE
OF PERSON
SIGNING
‘14
DATE
jopt/onalJ,
ATF
F 5100.24
(4-99)
1
GENERAL
You must file thus applrcation tf you want a permrt under
the Federal Alcohol Admrnrstratron
Act (FAA Act) to engage In the
business of
Producrng or processmg
drstrlled
nonrndustrtal
use
Importing Into the Unrted Stales,
beverages
sprrits or wine mcludes
COMPLETING
AND
FILING
THIS
rrdepen3ercesql0ew
NJ Mf
Fhladeiphra
PA.F?I, VT
2’55972246
PA 191CWX8
8097665584
RERTOFKX
for
NL OlHEER STATES
or wholesalmg,
alcoholrc
3
LABEL APPROVALS
FOR BOTTLED
ALCOHOLIC
BEVERAGES
Bottlers,packagers.
and importers should have ATF approved label
certrfrcates (ATF F 5100 31) A label approval is required to sell.
shop or delrver for sale or shrpment, or to otherwise Introduce in
Interstate or foreign commerce,
alcoholic beverages
Also, a label
approval allows Importers to release specrfic Imported alcoholrc
For label approvals contact the
beverages
from Customs’ custody
Product Compkance
Branch, ATF, Washington,
DC 20226
(202-927-8140)
ATF does not approve certrfrcates until you have
You can submrt draft labels
the appropriate
FAA Act basic permrt
(for example. mockups)
to ATF for review before printing the
labels
Trade name approval on your FAA Act basrc permrt does
not constitute approval as a brand name for labelrng purposes
4
SPECIAL TAX
If you operate a drstrlled spirits plant or bonded
wane premises or deal rn beer, wine or disblled spirits. file
ATF F 5630 5. Special Tax Regrstratron
and Return, and pay an
annual tax File ATF F 5630.5 and pay thus tax when you start
You do not file thus
selling. or offer for sale, alcoholrc beverages
form or pay specral tax when your busmess only Involves the
rmportahon or sale of fermented
cereal beverages whrch have an
alcoholic content of less than % percent or where your busrness IS
only In Puerto RICO
5
EMPLOYER
IDENTIFICATION
NUMBER
You need to have thus
number for your busrness even If you do not have any employees
To obtatn an EIN. file Form SS-4 with the Internal Revenue Service
Nonindustrtal
use of drshlled sprrtts or wines tncludes all beverage
purposes or uses rn preparing foods or drmks
Wholesalrng
under
the FAA Act means purchasmg
alcoholrc beverages
for resale at
wholesale
The FAA Act defines alcoholrc beverages
as drstilled
spmts. wane. or malt beverages
rncludrng any fermented
cereal
beverages
whrch have an alcohol content of less than % percent
2
CT~IV14M)fvEIJ-i
APPLICATION
Please type or print and complete all items
Write “not applrcable” in any item requesbng informatron
that does
not apply to your business
Items 8 through 11 If thus rnformatron is on file with ATF, state
“On file under (name and ATF permt or reg/sfry number or type of
pendmg app/rca0on)
If you need addibonal
room, use a separate sheet
If your producing
or processrng operatrons WIII be I” Puerto RICO.
contact the Chref. Puerto Rico Operatrons,
for addrtional requrremerits
Send this form in duplicate to the appropriate
ATF (Bureau of
Alcohol, Tobacco and Frrearms) offrce
Send to
ATF
Tei@WZNJfWEf
221 I&nStraet. 1lthRm
SanFrarasco, CA 941M1931
415744701?
PRIVACY
ACT INFORMATION
1
AUTHORITY
Solrcrtahon of mformabon
on ATF F 5100 24 IS made pursuant to 27 U S C Sectron 204(c)
Drsclosure
applrcant IS mandatory
if the appltcant washes to obtarn a basrc permrt under the Federal
Alcohol Adminrstratron
Act
2
PURPOSES
3
ROUTINE
USES
The informatron
wrll be used by ATF to make delemrnahons
set forth In paragraph 2 above
Where such drsclosure is not
prohibrted. ATF offtcers may disclose thus Information
to other Federal, State foretgn and local law enforcement
and regulatory agency personnel
to verrfy information
on the applrcabon and for enforcement
of the laws of such other agency
The rnformahon
may be drsclosed to the Justice
ATF officers may drsclose the informahon
to mdtvrduals to verrfy mformation
on
Department
If the applrcabon appears to be false or mrsleadrng
the applicahon
where such drsclosure IS not prohibrted
4
EFFECTS
OF NOT SUPPLYING
INFORMATION
lnformatron
1s not complete or mrsslng
REQUESTED
5
DISCLOSURE
OF EMPLOYER
IDENTIFICATION
These numbers are used to rdentrfy an rndrvrdual
NUMBER
AND SOCIAL SECURITY
NUMBER
If you do not supply the numbers,
or busrness
To Identify
the applicant.
the locahon
of the premrses,
PAPERWORK
and to determme
the eligibrlity
ATF may delay or deny the issuance
REDUCTION
ACT
of the applrcant
of this mformatlon
to obtain
by the
a basrc permit
of the FAA Act basrc permrt where
You do not have to supply these
your apptrcatron may be delayed
numbers
NOTICE
Thus request is in accordance
wrth the Paperwork
Reductton of 1995
The rnformahon collectron is used to determine
the elrgrbility of the applicant
to engage in certatn operations,
to determine the location and extent of operabons,
and to determine
whether the operations
WIII be In conformity
wrth Federal laws and regulations
The Information
requested
IS required to obtain or retain a benefit and is mandatory
by statute (27 U S C 203
and 204 (c))
The estimated
average burden assoctated
with thus collectton of rnformatron IS 1 hour and 45 mrnutes per respondent
depending
on rndrvrdual
crrcumstances
Comments
concernrng
the accuracy of thts burden estimate and suggestions
for reducmg this burden should be addressed to
Reports Management
Officer. Document
Services Branch, Bureau of Alcohol, Tobacco and Firearms, Washrngton,
DC 20226
An agency may not conduct
OMB control number
ATF F 5100.24
(4-99)
or sponsor
, and a person
IS not requrred
to respond
to, a collection
of mformahon
unless
It displays
a currently
vaird
3131OSEiO
1VAOtlddV
311108/138’fl
40 NOlld~3X3/N011V’3l~llt133
ClNt’ &IO3 NOIlV3llddV
s~tlv3w
aNv
033vaol
AtlnSV3tll3Hl~O
(L002116:c)
z6oo-zlsl
‘io~03iv
3&W SNOlllCl3
SnOlA3Ud
dv i. -.-~
(86-t’)
%-.
CC OOCS 4 JlV
~
~0 nvmna
13
ai
lN3b’JltlVd3Cl
AlNO
3Sll
JlV
809
ON avJ0
33110N 13VN0113n~3~
HklOLQl3dVd
DEPARTMENT
OF THE TREASURY
BUREAU OF ALCOHOL, TOBACCO AND FIREARMS
550 MAIN STREET, ROOM 8002 FEDERAL OFFICE BUILDING
CINCINNATI, OHIO 45202-3263
405030
IMPORTER
INFORMATION
for your
we are enclosing
the necessary
forms
As requested,
lesaler's
"
who
in applyizg
for an importer's
basic
permit.
unless
you will
be :;eII.ing
alcoholic
permit
is not required
other
than those
you plan to import.
beverages
The enclosed
in duplic:;?te
submitted
to
application
in accordance
this
office.
on ATF Form 5100.24
with
the instructions
use
bas ic
shoa!d
be compieted
on the form and
in Item 12 by an agent
of C?.? applicant
(someone
if it is zfgred
3
oower
of
attorney
other
than those
persons
listed
in Item 91,
We are enclc;s ii;;? ATF Form 5000.8,
must be fF:-ed for that
agent.
which may be used for ~iiis
pilrpose.
Fower cf. ;!tt ::rney,
ATF personnel
as necessary
may request
additional
to verify
the application.
information
from
applicants
products
that
will
Label
approval
must be obtained
for those
For this
purpose,
we are enc1oslnc-r
,‘iTF F 5100.31,
importea.
..:f Label/Bottle
Applicat
ion for and Certification/Exemptiori
This
forx
should
be
sent
tc:
Approva,.
be
Tobacco
and Firearms
Bureau
of Alcohol,
650 Massachlwetts
Avenue
NW
20226
Washington,
D.C.
ATTN:
Alcohol
Labeling
C Formulation
Division
On or before
the date you commence
Special
must file
ATF Form 5630.5,
and pay special
tax as a wholesaler.
and payment
must be sent to:
operations
as an importer,
you
Tax Registration
and Return,
This return
Please
note:
Tobacco
Bureau
of Alcohol,
P.O.
Box 371962
PA
15250-7962
Pittsburgh,
and
Firearms
If you begin business
after
the m!r,nth of .Iu?y, the tax is
sho;$n I:!
the monthly
rate
prorated
and is computed
by multi- ciying
number
of
mont1h.s
remaining
I:: *-!:::
column
(b) of the retlirn
ky the
including
~i;e :7:,':th pL; begi.n busi.ness.
tax year,
If you do not have an EraF1o\Ter Identification
Number,
you shou--::
the enclosed
Form SS-4 and sending
'.t
apply
for one by compieting
to the Internal
Revenue Service
as explained
on Page 2 of the
general
instructions
attached
to the form.
items
of the application
an3
Please
be sure that
~11 necessary
Your
failure
to
completed.
supporting
forms are properly
required
forms will
result
in a delay
in
properly
complete
all
the issuance
of your permit.
If an individual
listed
o:! the application
is a citizen
of a
foreign
country,
lived
i:: a foreign
country
for more than two
with
a forei.g:-:
years
(after
18 years of 3ge) or has association
the enclosed
Interpol
Questionnaire.
please
complete
country,
-,r-i for this
operation
are eligible
for
If the premises
to be ust<>
the National
Register
of 'iistoric
Places,
you should
not begi:the State
const ruction
or remode 1 in ; ant I 1 you iiave contacted
:'?<i I :lre to comply with
this
Historic
Preservation
Gtrl:;el-.
For
additia_<L
requirement
could
delay
_.;;suan:;e cf your permit.
see enclosed
instructions.
information
on this
subject_,
If you have
513-684-3337
any
or
please
quest:ons,
l-8OC-395-2282.
contact
Enclosures
WWW.ATF.TREAS.GOV
this
office
at
OMB
DEPARTMENT
BUREAU
APPLICATION
1.
OF ALCOHOL,TOBACCO
ALCOHOL
ADDRESS
3
.4
TELEPHONE
NUMBER
State In whtch orgamzed
2
6
MAILING
ADDRESS
BUSINESS(ES)
a /I-!
(
)
for Corporations
(W dffferent
and Llmited
from premrses
TO BE CONDUCTED
Llabillty
Companies
5
ADDRESS
(Check
DISTILLED SPIRITS PLANT
(BEVERAGE)
‘[ ’ DISTILLING
,~. WAREHOUSING
AND BOTTLING DISTILLED SPIRITS
PROCESSING
(RECTIFYINGJ
DISTILLED SPIRITS AND WINE
b 1 ~j BONDED WINE PREMISES
7: PRODUCING
AND BLENDING
‘-‘ BLENDING WINE
ADMINISTRATION
..~_.~
__--~- ACT ~~
EMPLOYER IDENTIFICATION
NUMBER (EIN)
(Social Security number IS not acceptable)
OPERATING
NAME
app//cable
LABELING
TRADE
wAs0~
I-1
a !A
b
8
If any
NAME(S).
if any
boxes)
c
IMPORTING
INTO THE UNITED
DISTILLED
SPIRITS
,~ WINE
MALT BEVERAGES
d
PURCHASING
FOR RESALE
:
DISTILLED
SPIRITS
!--’ WINE
:
MALT BEVERAGES
WINE
STATES
AT WHOLESALE
or while so engaged, sell, offer, or deliver for sale, contract to sell, or ship In Interstate or foreign commerce the alcoholic
produced, rectlfled, blended or bottled, warehoused
and bottled, Imported or purchased for resale at wholesale
7.
(DBA).
(LLC)
address)
AT PREMISES
(03/31/2002)
AND FIREARMS
FOR BASIC PERMIT UNDER THE FEDERAL
FULL NAME AND PREMISES
NO. 1512-0089
OF THE TREASURY
beverages
SO
dIstIlled
FOR THE APPLICATION
NEW BUSINESS
Anhclpated start date
- CHANGE IN OWNERSHIP
Date of Chanye ~~
._~~~~..--.
Name, address and permit number(s)
C
_~~~ ~_
of predecessor
CHANGE IN CONTROL
(Actual or legal)
.~ _’ Submit Basic Permit(s) with this appllcabon
Date of Change ~~~~-~-.....
---
OWNER INFORMATION
than 10% votmg stock
(List so/e owe;
a// general part/es, LLC members/managers.
corporate
Each irsled person must a/so furnrsh the vlformation m Rem 9 )
% VOTING STOCKIINTEREST
(If appBcab/e)
TITLE
NAME
officers
and dfrectors,
INVESTMENT
IN
BUSINESS
(Item 6)
and shareholders
wrth more
SOURCE OF FUNDS INVESTED
: (savmgs. loans. grft or specrfy other)
_---m~%ti&it%
IS ACTUALLY OR LEGALLY-oNTRollED-svPERSONS
SHEET INFORMATION
(as speohed for /tern 9) FOR EACH PERSON
BUSINESSES
SHOULD INCLUDE THEIR EIN
9
COMPLETE
a. FULL
GIVEN
FOR EACH PERSON
e
j
g
f
] MALE
RESIDENCE(S)
ATF F 5100.24
LISTED
NAME
OTHER
IN ITEM 8
~b DATE AND
BIRTH
NAMES
USED
FEMALE
OVER THE LAST
(4-99)
(Replaces
FIVE YEARS
ATF F 5170.4)
(Ma/den
PLACE
name,
ok ti~~~k~~~~OT
IDENTIFIED
ABOVE, PROVIDE
OR BUSINESS
AND STATE THE EXTENT AND MANNER
OF
mcknames,
c
SOCIAL SECURITY OR EMPLOY-RE
IDENTIFICATION NUMBER
etc)
ON A SEPARATE
OF THE CONTROL
YOU A U.S CITIZEN?
~
~
,--,
YES
:~-I
NO
a
FULL
GIVEN
b
NAME
DATE AND PLACE
BIRTH
OF
c
SOCIAL SECURITY OR EMPLOYER
IDENTIFICATION NUMBER
,d
ARE YOU A U S CITIZEN?
NO
YES
e
f
MALE
i-
o~ER?$%t!sUsED
(Ma/den
name,
mcknames,
etc )
FEMALE
g
RESIDENCE(S)
a
FULL
GIVEN
OVER THE LAST FIVE YEARS
b
NAME
DATE AND PLACE
BIRTH
c
OF
SOCIAL SECURITY OR EMPLOYER
IDENTIFICATION NUMBER
Id
ARE YOU A U S CITIZEN?
NO
1 YES
e
‘f
MALE
I-’
FEMALE
CJ RESIDENCE(S)
a
FULL
OVER THE LAST
GIVEN
~ 1
: 2 MALE
g RESIDENCE(S)
FEMALE
a
NAME
/f
1
(Ma/den
name,
nlcknames,
etc)
FIVE YEARS
OTHER
NAMES
‘f
OTHER
DATE AND PLACE
BIRTH
I
USED
:c
OF
SOCIAL SECURITY OR EMPLOYER
IDENTIFICATION NUMBER
Id. ARE YOU A U S CITIZEN’
~1
(Ma/den
name,
mcknames,
NO
YES
L
etcj
FIVE VEARS
b
e
:
USED
jb
!
OVER THE LAST
FULL GIVEN
MALE
NAMES
NAME
e
g
OTHER
j
NAMES
DATE AND PLACE
BIRTH
USED
(MaIden
name,
,c
OF
nicknames.
SOCIAL SECURITY OR EMPLOYER
IDENTIFICATION NUMBER
’d
I
ARE YOU A U S CITIZEN’,
-
NO
YES
etc)
j FEMALES
RESIDENCE(S)
OVER THE LAST
FIVE YEARS
10
HAS THE APPLICANT
OR ANY PERSON LISTED FOR ITEMS 8 OR 9 EVER BEEN DENIED A PERMIT, LICENSE OR OTHER AUTHORIZATION TO ENGAGE
IN ANY BUSINESS
TO MANUFACTURE,
DISTRIBUTE,
IMPORT,
SELL OR USE ALCOHOL
PRODUCTS
(beverage
or
nonbeverage)
BY ANY GOVERNMENT
AGENCY
(federal.
Slate. local or foreign) OR HAD SUCH PERMIT, LICENSE OR OTHER AUTHORIZATION REVOKED,
SUSPENDED
OR OTHERWISE
TERMINATED7
11
HAS THE APPLICANT
OR ANY PERSON LISTED FOR ITEMS 8 OR 9 EVER BEEN ARRESTED
FOR, CHARGED
WITH, OR CONVICTED
OF ANY CRIME UNDER FEDERAL,
STATE OR FOREIGN
LAWS other than traffic wolatlons
or convrcbons that are not felonies under
Federal or State law
YES
State details
of each event
on a separate
sheet
NO
NO
YES. State detatls of each event on a separate sheet
_If you are applymg for a basic permit to operate a dlstllled splnts plant
ATF MAY REQUIRE additional
information
to process
this application.
OPERATION
WITHOUT
A
or bonded wme premises, you must also file addItIonal forms and InformatIon
required under the Internal Revenue Code
PERMIT.
Cnmlnal and admmrstratlve
actions may be taken against persons engaged In a business listed in Item 6 of thts form If It IS not conducted
pursuant to an FAA Act basic permit
APPClCANT’SAFFIRMATION~-Underpenaltles
of perjury, I declare that I have examined this application,
mcludlng accompanymg
statements,
and
The applicant will Immediately
notify the ATF official with whom this
to the best of my knowledge
and belief, It IS true, correct and complete
applrcation
IS filed of any change in ownership,
management,
or control of the applicant
(In the case of a corporatron,
any change m the offfcers,
d!rectors, or persons holdrng 10 percent or more of Ihe corporate stock)
The busmess for which this applrcabon IS made does not violate the law
of the State In which the busmess WIII be conducted
In addltlon, If this appllcatlon
IS approved, the applicant will conduct operations
wIthIn a
reasonable
period of time and maintam such operations
In conformity
with Federal law
12 APPLICANT’S
SIGNATURE
(Sole owner, partner. corporate
officer, LLC member or manager, or rf desrgnated agent. subm!t
ATF F 5000.8)
15
E-MAIL
(INTERNET)
ADDRESS
(opt/&a/)
13 TITLE
OF PERSON
SIGNING
‘14
DATE
INSTRUCTIONS
1
GENERAL
You must file thts applrcatron If you want a permit under
the Federal Alcohol Admrnrstratron
Act (FAA Act) to engage in the
busmess of,
Producrng or processing
distrlled
nonrndustnal
use
lmportmg rnto the Unrted States,
beverages
sprrrts or wme mcludes
COMPLETING
AND FILING
2’5597-2246
FLERT)
~edenco Dega’au Federal Bldg
-a:0 Ray P7 009:8-!746
809-766-5584
550 Man s:reet
Cinc!nna:, O H 45202.3263
800-398-2282
%iC
ALL OikiEQ STATES
or wholesalmg,
alcohotrc
LABEL APPROVALS
FOR BOTTLED ALCOHOLIC
BEVERAGES
Bottlerspackagers.
and Importers should have ATF approved label
certificates (ATF F 5100 31) A label approval IS required to sell,
ship or delrver for sale or shtpment, or to otherwrse Introduce in
Interstate or forergn commerce,
alcoholrc beverages
Also, a label
approval allows Importers to release specrfrc imported alcoholic
For label approvals contact the
beverages
from Customs’ custody
Product Complrance
Branch, ATF, Washington,
DC 20226
(202-927-8140)
ATF does not approve certrfrcates until you have
the appropriate
FAA Act basic permrt
You can submtt draft labels
(for exampie, mockups) to ATF for revrew before pnntrng the
labels
Trade name approval on your FAA Act basic permit does
not constrtute approval as a brand name for labelrng purposes
THIS APPLICATION
Please type or print and complete all Items
Write “not appltcable” rn any Item requestrng mformatton
that does
not apply to your business
items 8 through 11 If thts rnformatron IS on ftle with ATF. state
“On file under (name and ATF permrt or regrslry number or type of
pendrng app//cat!on)
If you need addrtronal room, use a separate sheet
If your producing or processing
operations WIII be cn Puerto RICO,
contact the Chref. Puerto RICO Operatrons,
for addrtronal requrrements
Send this form In duplicate to the appropriate
ATF (Bureau of
Alcohol, Tobacco and Firearms) offrce
Send to
ATF
SPECIAL TAX
If you operate a drsttlled sprrits plant or bonded
wine premrses or deal rn beer, wine or distilled spirits, file
ATF F 5630 5. Specral Tax Regrstratton and Return, and pay an
annual tax Frle ATF F 5630 5 and pay thus tax when you start
selltng, or offer for sale, alcoholrc beverages
You do not file this
form or pay specral tax when your business only involves the
rmportatrori or sale of fermented cereal beverages which have an
alcoholrc content of less than % percent or where your business IS
only rn Puerto RICO
Telephone Number
22’ Mdcn Street 1 l!h Floor
San Franc~sco CA 94105.1931
EMPLOYER
IDENTIFICATION
NUMBER
You need to have thus
number for your business even If you do not have any employees
To obtarn an EIN, file Form SS-4 wrth the Internal Revenue Service
415-744-701’
PRIVACY
1
:tkpencence Sqw? ‘west
t’h’ladeiphia PA 19’06.3308
for
Nonrndustnal
use of drstrlled sptnts or wanes tncludes all beverage
purposes or uses in preparing foods or drinks
Wholesalrng
under
the FAA Act means purchasmg
alcoholrc beverages
for resale at
wholesale
The FAA Act defines alcoholrc beverages
as drstilled
sprnts. wme, or malt beverages
mcludmg any fermented
cereal
beverages
whrch have an alcohol content of less than % percent
2.
CT GE hlA hlD VE NH
NJ NY PA RI ‘I:
ACT INFORMATION
AUTHORITY
Solrcrtatron of rnformatron on ATF F 5100 24 IS made pursuant to 27 U S C Sectron 204(c)
Drsclosure
appltcant IS mandatory
If the applrcant wishes to obtam a basrc permrt under the Federal
Alcohol Admrnrstratron
Act
PURPOSES
To identify
the applrcant:
the location
of the premrses;
and to determine
the eligrbrlrty
of the applrcant
of thus informatlon
to obtain
by the
a basic permit
ROUTINE USES
Where such drsclosure IS not
The rnformatron WIII be used by ATF to make detemrnabons
set forth rn paragraph 2 above
prohrbrted, ATF officers may drsclose this mformatron
to other Federal, State forergn and local law enforcement
and regulatory
agency personnel
The information
may be drsclosed to the Justrce
to verify rnformatron on the applrcabon and for enforcement
of the laws of such other agency
Department
rf the applrcabon appears to be false or misleading
ATF officers may drsclose the mformatfon
to mdrvrduals to verify tnformatron on
the application
where such drsclosure IS not prohtbrted
EFFECTS
information
OF NOT SUPPLYING
INFORMATION
IS not complete or mrssrng
DISCLOSURE
OF EMPLOYER
IDENTIFICATION
These numbers are used to rdentrfy an indrvrdual
REQUESTED
ATF may delay
or deny the rssuance
NUMBER AND SOCIAL SECURITY
NUMBER
If you do not supply the numbers,
or bustness
PAPERWORK
REDUCTION
ACT
of the FAA Act basrc permrt where
You do not have to supply these
your application
may be delayed
numbers
NOTICE
Thus request IS rn accordance
wrth the Paperwork
Reductton of 1995
The mformatron collectron is used to determme the elrgrbiltty of the applicant
to engage in certain operattons,
to determine the locatron and extent of operabons,
and to determme whether the operatrons WIII be in conformity
wrth Federal laws and regulatrons
The rnformatron requested IS requrred to obtain or retarn a benefit and IS mandatory
by statute (27 U S C 203
and 204 (c))
The estimated average burden assocrated with this collectron of rnformatron IS 1 hour and 45 mtnutes per respondent
depending
on mdrvrdual
crrcumstances
Comments
concernrng
the accuracy of thus burden estrmate and suggestrons
for reducrng thus burden should be adcfessed
to
Reports Management
Officer, Document
Services Branch, Bureau of Alcohol, Tobacco and Frrearms. Washrngton.
DC 20226
An agency may not conduct
OMB control number
ATF F 5100.24
(4-99)
or sponsor
, and a person
IS not required
to respond
to, a collectron
of rnformatron
unless
It drsplays
a currently
valid
OMB No. 1512-0092 (3/31/2001)
FOR ATF USE ONLY
DEPARTMENT
~_~
ID
BUREAU OF ALCOHOL,
APPLICATION
CT
i
OF THE TREASURY
AP
OR
VENDOR CODE (Required)
2 SERIAL NUMBER lfWJiredl??
YEAR
-
I
/
/
I
TOBACCO
AND FIREARMS
FOR AND CERTIFICATION/EXEMPTION
LABEL/BOTTLE
APPROVAL
(See lnstructlons and Paperwork Reduction Act NotIce on Back)
PART I -APPLICATION
NAME AND ADDRESS
OF APPLICANT
AS SHOWN ON PLANT R&TRY,
PERMIT OR BREWER’S NOTICE (Required)
OF
BASIC---
3 BRAND NAME (Required)
4 CLASS AND TYPE (Required)
des!gnabon, rf appl/cable)
(Includes wme vanetal
/ 7a MAILING ADDRESS,
5 :I::
NAME (If any)
IF DIFFERENT
--j
6 PLANT REGISTRY/BASICPERMIT NO IBREWER’SNO
16 TYPE OF APPLICATION
0
(Check appkab!e box)
CERTIFICATE OF LABEL APPROVAL
17 SHOW ANY WORDING (a) APPEARING ON MATERIALS FIRMLY AFFIXEL’TO TtjE Cs2h7A1NER(e g caps, celoseals, corks, etc) OTHER THAN THE LABELS AFFIXED BELOW OR (D) EMBOSSED ON
THE CONTAINER THIS WORDING MUST BE NOTED HERE EVEN IF IT DUPLICATES PORTIONS OF THE LABELS AFFIXED BELOW ALSO, PROVIDE TRANSLATIONS OF FOREIGN LANGlJAGE TEXl
APPEARING ON LABELS
PART II - APPLICANT’S
CERTIFICATION
that all statements appeasing on this application are true and correct to the best of my knowledge and belief,
Under the penalties of pequry I declare
lncludtng supplemental
documents,
truly and correctly
represent the content of the
and, that the representations
on the labels attached to this form
i also cen~fv that I have read, understood and cornpIled wrth the wnditlons
and ~nstructtons which
containers to which these labels will be applied
appear on the reverse of an ongtnal ATF F 5100 31, CertlhcateiExemptlon
of LdbeliBottle Approval
18 DATE OF APPLICATION
21 DATE ISSUED
19. SIGNATUREOF APPLlCANr OR AClTHCRlZED AGENT
20 TYPE NAME OF APPLICANT
OR AUTHORIZED
__-PART Ill - ATF CERTIFICATE
This certlflcate IS issued subject to ap&able
laws regulations and conditrons as set forth on the back of thts form
22. AUTHORIZED SIGNATURE. BUREAU OF ALCOHOL, TOBACCO AND FIREARMS
AGENT
--
I
FOR ATF USE ONLY
QUALIFICATIONS
EXPIRATION
AFFIX COMPLETE
SET OF LABELS BELOW
DATE (If any)
.
.v By detel!ng :ii -o?;~;~r; ? ‘II 21 nal,.
*fi dentlficalionnumber or ctner serial numbers
I. CONDITIONS
1
This cerl~ficate1sIssueg foi A iF us? cniy Ths certlficale does ~01constitute lrademark prOtKhOn
2
This certificate does no! rele~e anv persx from liability for vioiaflons oilhe Federal A!cohol Admln~
lslration Act the AlcohomIcBeverage LabelingAct of 1988 the Internal Revenue Code related regulatK)nsor tullngs This certlficale au:hcr,zes use of the labels submltted in conjunctionwllh the applecabon for certificate only where ihe labels are used in accordancewrth the provisions of appircable
laws and regulations
3
For an> addItIonallnfcri?at~:r : lease con’x! Ibe Product CompilanceBranch at (2C2)927.8140,or wn!e
!o 0s at the &ress ~cttd .fl “e,’ : of :ne l&era1 Instructtons
II GENERAL INSTRUCTIONS
I
INSTRUCTIONS.Appi;caricnsMUST be pnntec or lyped sIgned in Ink and submrnedm duplxate
IOthe Product Compliance Branch, Bureau of Alcohol, Tobacco and Ftrearms, Washmgton,DC
20226 Exact copies nf 4TF r 5100 31 may be used in lieu of an origtnalblank form If submltbng
a copy, you do iiol need to mncludea copy of the reverse of the form aithoughyou reinam subject
to the lnstrucbonsand cond~!~ons
contaInedon Ihe reverse However, tl IS suggested thal ongtnai
ATF FSlGO31 be !,sed tinereier pcsslble A supply of forms may be obtatnedby contactingthe
ATF Oistrlbutior Center a: 1‘33) 455-7801 Applicattonsmusl generally be bled by the person, firm
or corporation wno wlisue :‘le bottler or packer of Ihe dlstllied spin6 wane,or mall beverages
However,for prmucrs lo be tmporledin contatnersintendedfor a sale at retaii, appkcatlonsmust be
filed by the Importer Ail appitcatlonsfor approvalof disbnbveliquor bottles musl Include phot@
graphs of bolh the fro11and back of Ihe botffe CERTIFICATESOF EXEMPTIONARE NOT
ISSUED FOR PRODti?S ‘MPORTED IN BOTTLES OR FOR MALT BEVERAGES
2
LABELS. All labels trai WII,appear on the bottle must be firmly affixed lo the form wrlh GLUE or
TAPE (DO NOT STAPLE) Printer’sproofs and photocopiesare acceptable If labels are m the
form of can Rals a pnotostatlccopy IS requested Pen and Ink changes whiting out lnformat~on,
typeovers, crossmg out tnfermatlon,and/or pasting labels over labels are prohlblled OversIze labels
must be reduced pno: 10affxlng to the appkcatlonform IndicateI” Item 17 that labels have been
reduced and the percentageof reduction A filled representativesample bottle must accompany
each appl~caboncovering etched/embossedcontaners or appkcabonswith acetale (ciear) labels
Except as further provided in condllton 4 below thls certificatecovers the products idenbfiedtn the
appllcatlonfor cert,ftcate ;: aulhonzes the removal of these productsfor mtrcductloninto commerce
from the plant where bottled o: DacKeo or from iusroms custody This certlficarernay be used to
remove lhese products on’1 irpcr I*e tollowng conditions
a ATF’s approval of the trade name of Ihe bonier or importer used on Ihe label (NOTE, Trade
name approval does not consbftie approvalas a brand name for lab&g purposes 1
b In the case of an Applicationfor Exemptjonfrom Label Approval, the exclusive dlsposdlonof the
product noted on Vie certificafe must be in the stale noled III Item 16b Each container must
bear the stalemenl “For Sale I” (State noted m item 166)only ”
4
CertlficahoniExelnptlonof Label!BottleApproval covers products in containers bearinga set of labels
identical to Ihe set affixed to Lhefront of this certificate It also covers products in contamers bearing
labels dlffenng in only Ihe followingways from those affixed to ttls certificate. IF YOU WISH TO
MAKE A CHANGE THAT IS NOT LISTED BELOW, A NEW LABEL APPROVAL IS REQUIRED
a In shape or proporttonatesze of labels
III. SPECIFIC lNSTRUCTlONS
b In net content statement However Ihe Buredu recommends submlsslon of separate appllcatlons for conlalners of 237 ml o( less. contamersover 237 ml lo 3 Illers and contamersover 3
Itters to insure compkance with the Alcoholic Beverage Lab&g Act of 1988 (Governmenf
WarnmgStatementj
ITEM
If you have nol been asslgned a vendor code number by ATF, leave this blank Submit thts
appllcakonform with a copy of your ATF Basic Permit or Brewers Notlce iNew FI!%s) so Ihat a
vendor code number can be assigned to you Use this number on all future appl~cattons
c In name and/or tradename of reswnsible wmery DSP, brewery or Importer provtdedthe name/
tradename has been added to origtnalBasic Permttor Brewers Nohce under which Ihe onglnal
label was Issued
If you have several vendo’codes asslgneo to your company, use the vendor code issued for the
address al which bortlipy relabelngor importationWI/Ioccur
d In name and/or adaress of the foreign producer bohler or shipper, If the producer, bonier, or
shlpper IS located in the same country onglnaily shown
You must assIgn a sequentialserial number begInnIngwith Ihe lasl two dtgits of Ihe current calendar
year to EACH APPLICATIONAND ITS DUPLICATE,NOT TO EXCEED 6 CHARACTERS.e g
98 1, 982, etc
e in statement of percentageof neutral spmts and name of commodity from which produced
provided tt does not alter lhe class and type
f
A brand name 6 the rame under which Ihe product IS sold If the product IS not sold under a brand
name the name of the bciiI?r packer or Importerbecomes the brand lame
In alcohol percentageoy YoIurre on d,slllleUspinis unless It allers the class and type
g In pmcd of age staleu L.!:IPSS
#t&IS the class and lype of the producl
i$ecrfy exact desrqnarlonunoer the standards of Ibenhtyin 27 CFR Parts 4 5, and 7e g Gin,
D~shlledSplnts Specldlty (OtherThan StandardWine Beer, Flavored Malt Beverage.Chardonnay
etc
h In statement of age and @z?rcent,age
on distilled sp~ntsprovidedil does not alter Ihe class and
type
I
l
A far&l name is a name whtch further ldenhflesthe product and IS requlrti for some spectalty
products It may be used for other products
In stated vintage date of wine or delellon of vantageyeaf NOTE If vintage date IS deleted no
referencelo ‘Vintage’may oe made on dny label or other malenals (e g caps celoseals corks,
efc) aft?& lo Ihe bonle ‘:iltage dates may NEVER BE ADDED, ONLY CHANGED OR
DELETED
This llem WIIIreflect the type of buslress filing the application (a) the plant reglstiy number Ifthe
applicant IS a bonier or paxi of dtstllled sptnts or wine, (b) the brewer’s notlce number If the appllcanl IS a brewer or (c) the importer’sbaz permit number If the appltcantIS an Impcfier of dlstllted
spmts, waneor beer ‘Wholesatenapplying to relabel should reflect the wholesaler’sbasic permrt
number in this Item
By ad&g a statementof net contents 13Ihe brand, back, or other label correspondfngto the
requ& statement shown elsewhere on the labels or blown lnlo the bottle
k In the case of mall beverages by adding delebng,or changmg a statement of aicohohccontend,
or other statements required by itie s!a!e ‘n whtch the beverage IS lo be sold
I
By addmg, deleting or changing on lhe brand or back label. the name and address or trademark
@both) of the wholesaler retailer M persons for whom Impott& or botlled, or by adding
another label slahng such lnformatlonprovidedthat no reference IS thereby made to the prtiuct
or any of Its characteristics
indicate kour company name and current address exactfy as they appear on your Plant Registry
Brewers NotIce or Bas c Perpi! iii;cil;de aoproved DBA or trade name used on iabel) A separate
malllng address nay aopei’ ?ect!y bnder the required name and address in Item 7a
7a If Item 7a does not penaln to you use this space to reflect mulhple plant lccatlons Cross out the
words ‘Malllng Address ,f different
8
m In stated amounl of sugar at haries! or residual sugar of wines
n In stated botrlrngdate
o In Lhecase of wines, a change I” Ihe alcohol content statement,If wIthIn the prescribed lkmllation
for that class or type of wine and w~lhrnthe same laxable grade
For any domestcally producedflavored malt beverageproduct or any domeshcallyproduced malt
beverage marketed under any name other than beer, lager, stout, etc a copy of the approved
statementof process or formula 1srequired
p In stated amount of acid or ph level One or both may be deleted from label
q In adding bonded winery number ir direct conluncl~onwith the bottlefs name and address
r
t
If your product requires a formula or statementof process (SOP) please do not submit your
applicabonfor label approval Jntll your formula or SOP IS approved,we will return any which are
submittedwIthout an approvedformula or approved SOP when required
In slated percentages for vanetal and/or appellabon (Must equal fCO%j
s In stated CaiorlccOnlentfor wine or olshlled spmts
In stated aver+e analysts for maif beveragesprowded change IS in complrancewth Industry
Circular 805
For any domestic wme and dlstliled splnts product requlnng a formula, show Ihe formula number
Attach a copy of the approved formula (except for vermotih) wllh the appleabon for label approval
For domestlc producls crccxed under a formula which was not manufacturedby the applicant, a
copy of the approved for&a rs requested but a stalement giving the name and address of the
producer and the formula number may be subsbtuted
9
For any Imported products .equlring preimporl approval,show the lab number and date of letler
A copy of this letter must be attached to the label appltcabonat the time of submIssIon
10 lpdicate the size joef contents) covered by label(s) affixed lo the appllcabon You may submit a
range of sizes, ,f known 8 ‘le !;me of sLbmlssion of the appllcatlon
u By adding or changlrg ti?C Code as permihed by Industry Circular 77-23
The recordkeepIngrequirementfor tnis informahoncollection IS 3 years
v By addIng,delebng or changing a web site address, phone number fax number or ZIPcode