Form TTB F 5230.5 TTB F 5230.5 Application for an Amended Permit under 26 U.S.C. 5712,

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

DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)

APPLICATION FOR AMENDED PERMIT UNDER 26 U.S.C. 5712
IMPORTER OF TOBACCO PRODUCTS
INSTRUCTIONS
This form must be filed in duplicate by every importer of tobacco products when required by 26 U.S.C. 5712 and the regulations in 27 CFR Part 41.
Both copies are to be filed with the National Revenue Center, Alcohol and Tobacco Tax and Trade Bureau.
All supporting documents required by the regulations, and any additional information the National Revenue Center may require, must be made part
of this application. All the information called for by the items below and any separate instructions relating to this form must be furnished. If
additional space is needed for any item, use the reverse or attach a separate sheet.
TO:

1. DATE OF APPLICATION
DIRECTOR, NATIONAL REVENUE CENTER
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
STE 8002
550 MAIN ST
CINCINNATI, OHIO 45202-5215

2. NUMBER OF PERMIT NOW HELD
3. EFFECTIVE DATE OF PERMIT NOW HELD

THE UNDERSIGNED HEREBY MAKES APPLICATION FOR AN AMENDED PERMIT AS INDICATED BELOW
4. NAME AND PERMIT ADDRESS

5. MAILING ADDRESS

6. EMPLOYER IDENTIFICATION NUMBER

7. DAYTIME TELEPHONE NUMBER (Including area code)

8. CHANGE OF LOCATION/ADDRESS (Number, street/route, city/town, county, State, and ZIP code)

ADDITION

10. CHANGE IN NAME

REASON FOR USE OF TRADE NAME

9. TRADE NAME
DELETION

The applicant agrees, by accepting the amended permit applied for herein, that issuance thereof shall not relieve him of any liability heretofore
incurred. All data, written statements, affidavits, evidence, or other documents heretofore filed and those submitted in support hereof, or upon any
hearing, shall be deemed to be a part of this application.
Under the penalties of perjury, I declare that all statements made in this application for amended permit, and all data, written statements, affidavits,
evidence, or other documents submitted in support hereof, or upon any hearing, are true to the best of my knowledge and belief.
11. SIGNATURE

12. TYPED OR PRINTED NAME

13. TITLE OR STATUS (State whether individual owner,
partner, member officer, or if officer of corporation, give
title)

ADDITIONAL INSTRUCTIONS
a. The permit to be amended must be attached to this application.
b. If State law requires registration of trade names, proof of registration must be submitted with this application. If State law does not require
registration, a statement to that effect must be included on this application.
c.

If the corporate name is changed, certified copies of amended Articles of Incorporation must be submitted with the application.

TTB F 5230.5 (4/2006)

PRIVACY ACT INFORMATION
The following information is provided pursuant to Section 3 of the Privacy Act of 1974 (5 U.S.C. 552(e)(3)):
1. AUTHORITY. Solicitation of this information is made pursuant to 26 U.S.C. 5712. Disclosure of this information by the applicant is mandatory in
order to obtain an amended importer of tobacco products permit.
2. PURPOSE. To identify the applicant, to identify the location where the applicant will conduct business, and to identify changes affecting the
accuracy of the applicant’s original importer of tobacco products permit.
3. ROUTINE USES. The information will be used by TTB to make the determinations set forth in paragraph 2. In addition, the information may be
disclosed to other Federal, State, foreign and local law enforcement and regulatory agency personnel to verify the information on the application
where such disclosure is not prohibited by law. The information may further be disclosed to Federal authorities if it appears that the furnishing
of false information may constitute a violation of Federal law. Finally, information may be disclosed to members of the public in order to verify
the information on the application where such disclosure is not prohibited by law.
4. EFFECTS OF NOT SUPPLYING INFORMATION REQUESTED. Failure to supply complete information will delay processing and may cause
denial of the application.
PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. This application is used to determine the eligibility of the applicant to
engage in certain operations, to determine location and extent of operations, and to determine whether the operations will be in conformity with
Federal laws and regulations. The information requested is mandatory by statute (26 U.S.C. 5712).
The estimated average burden associated with this collection is 1 hour 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 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 an individual is not required to respond to, a collection of information unless it displays a current valid
OMB control number.

TTB F 5230.5 (4/2006)