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

OMB No. 1513-0078 (00/00/0000)

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

APPLICATION FOR AMENDED PERMIT TO IMPORT TOBACCO
PRODUCTS OR PROCESSED TOBACCO
INSTRUCTIONS
This form must be filed by every importer of tobacco products or processed tobacco when required by 26 U.S.C. 5712 and the
regulations in 27 CFR Part 41. This application must 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 a 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

2.

NUMBER OF PERMIT NOW HELD

3.

EFFECTIVE DATE OF PERMIT NOW HELD

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

4.

NAME AND ADDRESS ON PERMIT NOW HELD

5.

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

6.

EMPLOYER IDENTIFICATION NUMBER

7.

DAYTIME TELEPHONE NUMBER (Including area code)

(

―

)

―

THE UNDERSIGNED HEREBY MAKES APPLICATION FOR AN AMENDED PERMIT AS INDICATED BELOW
8.

CHANGE THE

LOCATION/ADDRESS OR

MAILING ADDRESS OF MY BUSINESS TO IMPORT TOBACCO

PRODUCTS OR PROCESSED TOBACCO (Number, street/route, city/town, county, State, and Zip code)

9.

CHANGE IN TRADE NAME/

NAME(S)

OPERATING NAME(S)
ADDITION

DELETION

ADDITION

DELETION

ADDITION

DELETION

TTB F 5230.5 (05/2009) PREVIOUS VERSIONS SUPERSEDED AND MAY NOT BE USED

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10. CHANGE IN OPERATIONS AUTHORIZED –
PLEASE AMEND MY PERMIT TO AUTHORIZE IMPORTATION OF PROCESSED TOBACCO

The applicant agrees, by accepting the amended permit applied for herein, that issuance thereof will 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 will 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. TITLE OR STATUS *

13. TYPED OR PRINTED NAME

*(State whether individual owner, partner, member officer, or if officer of corporation, give title)

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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.

d. Issuance of an amended permit does not extend the expiration date of the permit. A person holding a current permit
to import tobacco products or processed tobacco must submit an application to renew the permit within 30 days of
the expiration date shown on the permit.

FOOTNOTE
1. A change in legal name often occurs as a result of a transfer of ownership. If there is a transfer of ownership, then
you must file TTB F 5230.4, not this form.
2. What is the legal name?
IF THE BUSINES IS A:

THE LEGAL NAME IS:

Sole Proprietorship

Sole proprietor’s full name

Partnership

The name of each partner or the name of the partnership as filed with
a State or local government

Corporation, association, limited liability
company or other business organization

The name as stated on the documents filed with the State or local
government

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 or
processed tobacco 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 or
processed tobacco 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 (05/2009) PREVIOUS VERSIONS SUPERSEDED AND MAY NOT BE USED

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