Form TTB F 5120.20 TTB F 5120.20 Ceertificate of Tax Determination - Wine

OMB No. 1513-0029 (11/30/2009)
FILED IN SUPPORT OF
TTB F 5120.246(5,$/
NO.
CERTIFICATE OF TAX DETERMINATION - WINE
or Claim F 5620.8.
(See Paperwork Reduction Act Notice Below)

DEPARTMENT OF THE TREASURY

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)

PART I - STATEMENT OF EXPORTER
I am the exporter of wines described below, and intend to file claim for drawback of tax thereon.
KINDS OF
WINES

(a)

AC
LO
CN
OT
HE
ON
L T

CASES
SERIAL NUMBERS
NO.
(Show fiOling date when use of such date
 OF
BOTTLES
TRADE OR has been authorized in lieu of serial
PACK- NUMBER
PER
numbers on cases)
BRAND NAME
AGES OF CASES
SIZE
CS.

(b)

1. DATE

(c)

(d)(e)(fJ

2. EXPORTER (Name and Address)

1. DATE

(hL

3. BY (Signature and Title)

3. BY (Signature and Title)

2. EXPORTER (Name and Address)

4a. TO: (Name and Address)

WINE GALLONS

PART II - REQUEST OF EXPORTER FOR CERTIFICATE
4b. My records indicate that the above described wines were:
Withdrawn by you on
Bottled or packaged by you
determination of tax
after determination of tax
Please execute the certificate (Part III) on all copies of
this form, and return the original and one copy to me at
the address shown above.
PART III - CERTIFICATE

5. Under penalties of perjury, I certify that the wines described above were manufactured or produced in the United States and were:
Bottled or packaged while in bond, and
were then withdrawn from bond by me on
determination of tax.

Withdrawn from bond by me on determination of
tax and were then bottled or packaged by me.

Bottled or packaged by me after they
were received in taxpaid status from:
(NAME, ADDRESS , AND 5(*,675< OR PERMIT NUMBER)
This certificate is executed with the knowledge that it will be used in support of a claim against the United States for drawback of tax.
6. DATE
8. BY (Signature and Title)
7. DEPONENT (Name and Address)
9. 5(*,675< OR PER
0,7 NO.
INSTRUCTIONS
1. A certificate of tax determination must be executed on this form to support a claim
filed by an exporter for drawback of tax on wines exported from the United States,
laden for use as supplies on certain vessels or aircraft, transferred to a foreign-trade
zone, or transferred for export to Armed Forces of the United States. Prepare an
original and two copies of the form (original and one if the exporter and the person
executing Part III of the form are the same).
2. Part III of the form is for certifying that the wines were produced or manufactured in
the United States and were properly tax paid on withdrawal from bond. This part may

TTB F 5120.20 (/200)

be executed only (a) by the person who withdrew the wine from bond on determination
of tax, or (b) if the wine was bottled or packaged after tax determination, by the person
who bottled or packaged it.
3. The exporter is responsible for securing a properly executed certificate. The
original of the form must be submitted to the Director, National Revenue Center, 550
Main St, Ste 8002, Cincinnati, OH 45202-5215. A copy of the form must be retained
by the exporter and by the person who executes Part III for 3 years.

PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. The information collected is used to support a claim filed by an
exporter for drawback of tax on wine exported from the United States. This information is mandatory by 26 U.S.C. 5062.
The estimated average burden associated with this collection of information is .5 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 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.

TTB F 5120.20 (/200)