Form TTB F 5230.4 TTB F 5230.4 Application for Permit under 26 U.S.C. Chapter 52, Impor

OMB No. 1513-0078 (12/31/2008)

DEPARTMENT OF THE TREASURY

FOR TTB USE ONLY

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)

PERMIT NUMBER AND DATE

APPLICATION FOR PERMIT UNDER 26 U.S.C. CHAPTER 52
IMPORTER OF TOBACCO PRODUCTS
(Please type or print. Read instructions)
1.

FULL NAME OF APPLICANT AND PREMISES ADDRESS

(Read instruction 6)

2.

EMPLOYER IDENTIFICATION NUMBER

3a. DAYTIME TELEPHONE NUMBER
(Including area code)
4.

MAILING ADDRESS (NOTE: TTB will use this address to correspond with you.)
c

5.

CORPORATE, PARTNERSHIP, OR ASSOCIATION DOCUMENTS ARE (see instr uction 7 and check approprate box)

3b. E-MAIL ADDRESS (optional)

NOT INCLUDED WITH THIS APPLICATION BECAUSE (state reason)

INCLUDED WITH THIS APPLICATION

6. TRADE NAME(S) UNDER WHICH BUSINESS IS TO BE CONDUCTED (If State, county, or municipal law requires trade name registration, a true copy of
th document
T e document
showing
regist must accompany this application. If registration is not required, so state in this application or in an accompanying
the
showing
registration
ertificatesubmitted
submittedinintwo
two copies.)
copies.)
certificate
a.

OPERATING NAME (DBA), IF ANY

b.

OTHER TRADE NAME(S), IF ANY

7.

REASON FOR APPLICATION (Check one box and provide andy additional information requested.)
a. APPLICANT IS STARTING A NEW BUSINESS OF IMPORTING TOBACCO PRODUCTS
b. RENEWAL OF PERMIT
c. APPLICANT INTENDS TO ACQUIRE OR HAS ACQUIRED THE BUSINESS OF ANOTHER PERSON WHO IS ENGAGED IN THE BUSINESS
OF IMPORTING TOBACCO PRODUCTS

(1) DATE BUSINESS WAS ACQUIRED OR WILL BE
ACQUIRED (month, day, year)

(2) NAME, ADDRESS, AND PERMIT NUMBER OF THE ACQUIRED BUSINESS

d. BECAUSE OF AN ACTUAL OR LEGAL CHANGE IN CONTROL, APPLICANT’S PERMIT (attached to this application) WILL TERMINATE
WITHOUT THIS APPLICATION OR HAS TERMINATED
STATE D ATE OF CHANGE IN CONTROL (month, da y, y ear)
8.

IS THE APPLICANT A CTUALLY OR LEGALLY CONTROLLED BY PERSONS NOT IDENTIFIED IN ITEM 13 OF THIS APPLICATION? (Check
your ans wer)
YES. Applicant will state the extent and manner of the control and identify the persons with the same information as item 13.

9.

NO

HAS THE APPLICANT OR ANY PERSON LISTED IN ITEM 8 OR 13 OF THIS APPLICATION EVER BEEN DENIED A PERMIT, LICENSE, OR
OTHER AUTHORIZATION TO ENGAGE IN ANY BUSINESS TO MANUFACTURE, EXPORT, OR IMPORT TOBACCO PRODUCTS BY ANY GOVERNMENT (Federal, State, local, or foreign) AGENCY, OR HAD SUCH PERMIT, LICENSE, OR OTHER AUTHORIZATION BEEN REVOKED, SUSPENDED,
OTHERWISE TERMINATED? (Check your answer)
YES. Applicant will state the details and reasons for each event involving the applicant or other person.

NO

10. DOES THE APPLICANT (INCLUDING ANY OFFICERS, DIRECTORS, OR PARTNERS) HAVE THE BUSINESS EXPERIENCE, TRADE CONNECTIONS, AND FINANCIAL STANDINGG TO START THE BUSINESS FOR WHICH THIS APPLICATION IS MADE WITHIN A REASONABLE PERIOD AND
TO CONFORM TO FEDERAL LAW? (Check your answer)
YES

NO

11. DOES THE BUSINESS FOR WHICH THIS APPLICATION IS MADE VIOLATE THE LAW OF THE STATE IN WHICH THE BUSINESS WILL BE
CONDUCTED? (Check your answer)
YES

NO

12. HAS THE APPLICANT OR ANY PERSON LISTED IN ITEM 8 OR 13 EVER BEEN ARRESTED,, CHARGED WITH, OR CONVICTED OF ANY
VIOLATION OR CRIME UNDER FEDERAL, STATE, OR FOREIGN LAWS OTHER THAN A MISDEMEANOR TRAFFIC VIOLATION OR
CONVICTION? (Check your answer)
YES (Applicant will attach details for each event )
TTB F 5230.4 (12/2008)

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NO

13. PERSONS INVOLVED OR WHO HAVE FINANCIAL INTEREST IN APPLICANT’S BUSINESS (Read instruction 8)
a. FULL GIVEN NAME (No initials)
b. OTHER NAMES USED (Include maiden and married)

d.

BIRTH DATE (Month, day, year)

c.

SOCIAL SECURITY NUMBER

f.

EMPLOYER IDENTIFICATION NUMBER (If business)

g.

e.

ARE YOU A U.S. CITIZEN?
YES

i.

RELATIONSHIP WITH APPLICANT’S B USINESS

k.

RESIDENCE OR PRINCIPAL PLACES OF B USINESS
DURING THE PAST 5 YEARS (Include both if individual
operated any business at a location other than residence.)

PLACE OF BIRTH ( City, town, State, or foreign country)

h.

NO

NUMBER AND TYPE OF SHARES HELD
(If person holds more than 10 percent)

j. INVESTMENT IN APPLICANT’S PERMIT BUSINESS (If more than 10 percent of capital)
(1) CURRENT
(3) SOURCE(S). Identify the person's name and address from
whom the investment comes and specify why the investment
$
is available (examples: savings, loan, gift)
(2) ANTICIPATED
$

a.

FULL GIVEN NAME (No initials)

c.

SOCIAL SECURITY NUMBER

f.

EMPLOYER IDENTIFICATION NUMBER (If business)

b.

d.

OTHER NAMES USED (Include maiden and married)

BIRTH DATE (Month, day, year)

g.

e.

ARE YOU A U.S. CITIZEN?
YES

i.

RELATIONSHIP WITH APPLICANT’S B USINESS

k.

RESIDENCE OR PRINCIPAL PLACES OF BUSINESS
DURING THE PAST 5 YEARS (Include both if individual
operated any business at a location other than residence.)

PLACE OF BIRTH (City, town, State, or foreign country)

h.

NO

NUMBER AND TYPE OF SHARES HELD
(If person holds more than 10 percent)

j. INVESTMENT IN APPLICANT’S PERMIT BUSINESS (If more than 10 percent of capital)
(1) CURRENT
(3) SOURCE(S). Identify the person's name and address from
whom the investment comes and specify why the investment
$
is available (examples, savings, loan, gift)
(2) ANTICIPATED
$

a.

FULL GIVEN NAME (No initials)

c.

SOCIAL SECURITY NUMBER

f.

EMPLOYER IDENTIFICATION NUMBER (If business)

b. OTHER NAMES USED (Include maiden and married)

d.

BIRTH DATE (Month, day, year)

g.

RELATIONSHIP WITH APPLICANT’S B USINESS

k.

RESIDENCE OR PRINCIPAL PLACES OF B USINESS
DURING THE PAST 5 YEARS (Include both if individual
operated any business at a location other than residence.)

PLACE OF BIRTH (City, town, State, or foreign country)

ARE YOU A U.S. CITIZEN?
YES

i.

e.

h.

NO

NUMBER AND TYPE OF SHARES HELD
(If person holds more than 10 percent)

j. INVESTMENT IN APPLICANT’S PERMIT BUSINESS (If more than 10 percent of capital)
(1) CURRENT
(3) SOURCE(S). Identify the person's name and address from
whom the investment comes and specify why the investment
$
is available (examples: savings, loan, gift)
(2) ANTICIPATED
$

14. ADDITIONAL INFORMATION. TTB may require additional evidence necessary to verify this application.

TTB F 5230.4 (12/2008)

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15. APPLICANT’S AFFIRMATION. Under penalties of perjury, I declare that I have examined this application, including accompanying statements, and to the
best of my knowledge and belief, it is true, correct, and complete. In addition, if this application is approved, the applicant will conduct operations within a
reasonable period of time and maintain such operations in conformity with Federal law. After filing and until final action is taken on this application, the
applicant will immediately notify the TTB official with whom this application is filed of any change in officers, directors, or persons holding more than 10
percent of the stock of a corporation or other business organization.
16. APPLICANT’S SIGNATURE (Read instr uction 9)

17. TITLE OF PERSON SIGNING

GENERAL INSTRUCTIONS FOR TTB F 5230.4

18. DATE

business organization, such as assocations or limited liability
companies; investor who provides more than 10 percent of the capital
required for the permit business; stockholder who owns more than 10
percent of the issued voting shares of the applicant (for example,
applicant is a corporation or other business organization that issues
stock). Do not include voting stock owned by the applicant, such as
“treasury” or unissued stock in the percent calculation.

1. GENERAL. File this application if you want a permit or are renewing
your permit to engage in the business of importing tobacco products.
Neither the filing of this application nor its approval allows a business
to violate State or local laws, such as registration of trade names and
licensing requirements.
2. COMPLETING AND FILING THIS APPLICATION. Complete all items.
Write “ not applicable” or a similar phrase in any item which requests
information not pertinent to your business. If you need additional room,
use a separate sheet. Put your name, date of application, and the item
number(s) on each separate sheet. File two copies of this form and any
attachments with:

9. ITEM 16 - If the applicant is an individual, the individual must sign. If
the applicant is a corporation, the president, vice president, or other
principal officer must sign. If the applicant is a partnership or other
unincorporated organization, all partners or a responsible and
authorized member or officer having the knowledge of its affairs must
sign. If the applicant is a trust or estate, the fiduciary must sign. If an

TTB National Revenue Center
550 Main St, Ste 8002
Cincinnati, OH 45202-5215

agent of the applicant signs, file an acceptable power of attorney (for
example, TTB F 5000.8) with this application.

Contact this office at 1-877-882-3277 if you have questions or need
additional information about this application.

PRIVACY ACT INFORMATION

3. INFORMATION TO FILE. This application may ask for information that
you have already filed with TTB. You may reference such information if
you filed it with a valid TTB permit or an application that is pending with
TTB. Reference the appropriate item(s) of this application. Include the
name of the applicant or the permittee, and the TTB permit number or
the type and date of the application.
4. OPERATIONS WITHOUT A PERMIT. In general, criminal or administrative actions may be taken against persons importing tobacco products
without a permit. The exception to this rule is when a change in control
occurs because of the issuance, sale, or transfer of the stock of a
corporation. A change in control occurs when the identity of the principal
stockholders exercising actual or legal control of a corporation changes.
In such case, the permittee must file an application within 30 days after
the change; otherwise, the permit is automatically terminated.
5. APPROVAL. If TTB approves your application, we will send you the
permit and a copy of your application.

The following information is provided pursuant to Section 3 and 7(b) of the
Privacy Act of 1974.
1. AUTHORITY. Solicitation of information on TTB F 5230.4 is made
pursuant to 27 U.S.C. 204(c). Disclosure of this information by the
applicant is mandatory if the applicant wishes to obtain a permit under
the Internal Revenue Code.
2. PURPOSES. To identify the applicant, the location of the premises, and
to determine the eligibility of the applicant to obtain an IRC permit.
3. ROUTINE USES. The information will be used by TTB to make determinations set forth in paragraph 2 above. Where such disclosure is not
prohibited, TTB officers may disclose this information to other Federal,
State, foreign, and local law enforcement and regulatory agency
personnel to verify information on the application and for enforcement
of the laws of such other agencies. The information may be disclosed to
the Justice Department if the application appears to be false or
misleading. TTB officers may disclose the information to individuals to
verify information on the application where such disclosure is not
prohibited.

SPECIFIC INSTRUCTIONS
6. ITEM 1 - Enter the full name of the individual if a sole owner; if a
partnership, the full name of all partners ; if a limited partnership, the full
name of the general partner; if a corporation, association, or limited
liability company, the cor porate or actual name . Include the number,
street, city, State, and Zip code. If the street address does not identify
the location, give additional information with the distance and location
from the nearest public road, intersection, or other landmark.
7. ITEM 5 - A corporation (including limited liability company) must submit (1) a true copy of the corporate charter or certificate of corporate
existence or incorporation , from the State in which it is incorporated and
(2) extracts of stockholders’ meetings, bylaws, or directors’ meetings
that list officers that the applicant has authorized to sign documents
or to act for the corporation. A partnership or association must submit
a true copy of articles or certificate of partnership or association where
State or local la w requires. If not required by State or local law, state
this fact in item 5.
8. ITEM 13 - Supply the information for any person, including an
individual who, or a business which is or will be a (an): sole proprietor
(individual owner) ; partner (including limited, active, or silent ). State
whether the partner is an active or inactive partner and whether the
partner’s involvement is silent or limited; officer or director of a
corporation or similar responsible postions for any other type of

TTB F 5230.4 (12/2008)

4. EFFECTS OF NOT SUPPLYING INFORMATION REQUESTED. TTB
may delay or deny the issuance of the Internal Revenue Code permit
where information is not complete or missing.
5. DISCLOSURE OF SOCIAL SECURITY NUMBER. You do not have to
supply the social securityy number of an individual. The social security
number is used to identify an individual. If you do not supply the number,
your application may be delayed.
PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. The
information is used to determine the eligibility of the applicant to engage in certain
operations, to detemine location and extent of operations, and to detemine whether
the operations will be in conformity with Federal laws and regulations. The
information requested is required to obtain or retain a benefit and is mandatory by
statute (26 U.S.C. 5712) .
The estimated average burden associated with this collection of information is 2
hours per respondent or recordkeeper, depending on individual circumstances.
Comments concerning the accuracy of this burden estimate and suggestions for
reducing this burden should be addressed to the Reports Management Officer,
Regulations and Rulings Division, Alcohol and Tobacco Tax and Trade Bureau,
Washington, DC 20220.
An agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information unless it displays a current, valid OMB control number.

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