Form TTB F 5000.21 TTB F 5000.21 Referral of Information

OMB No. 1513-0003 (01/31/2011)
U.I. NUMBER

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

REFERRAL OF INFORMATION
(See Instructions on page 2)
PART I - REFERRAL
1. TO: (title, agency, and address)

2. DATE

The following information and attachment (Check applicable box)
as potential criminal or civil violations coming under your jurisdiction.

are sent to you as requested,

COMPLETE FOR REFERRALS OR REQUESTS OUTSIDE TTB under 26 U.S.C. 6103.

DOES

COMPLETE IF APPLICABLE: This is a confirmation of a referral made
3. NAME(S) OF PRINCIPALS INVOLVED IN POSSIBLE VIOLATION

are referred to you for consideration

DOES NOT contain confidential returns or return information

by telephone

in person on ______________________.

4. STATUTE(S) POSSIBLY VIOLATED

5. FEDERAL LICENSES AND/OR PERMITS HELD (type and number)
6. TTB OFFICER UNCOVERING POTENTIAL VIOLATION

7. POST OF DUTY

8. SUMMARY OF SIGNIFICANT FACTS AND/OR EXPLANATION OR DESCRIPTION OF ATTACHMENT (Continue on a separate sheet, if necessary)

9. TTB OFFICIAL APPROVING REFERRAL (Signature)

10. DATE

11. TITLE AND ADDRESS

12. TELEPHONE NO.

PART II - RESPONSE (See Instruction 4)
1. THE REFERRAL ABOVE IS

ACCEPTED

REJECTED (Explain below)

REQUESTED

OTHER (Explain below)

NOT REQUESTED
2. DATE

3. ACTION PLANNED OR TAKEN AND COMMENTS (Continue on a separate sheet, if necessary)

4. SIGNATURE

5. TITLE OF OFFICIAL

6. ADDRESS

COMPLETE FOR REFERRALS WITHIN TTB: THIS RESPONSE IS
TTB F 5000.21 (02/2008)

7. TELEPHONE NO.

INTERIM

FINAL

INSTRUCTIONS
1. PURPOSE.
Use this form to internally refer potential violations of TTB administered
statutes and to externally refer to the appropriate Federal, State, or
local enforcement/regulatory agency potential violations of other
statutes. Also, use this form to transmit information (including
confirmation of oral transmittals) to, or to document inspections
(on-site) by, another Federal, State, or local agency, that identifies,
directly or indirectly, a licensee permittee, taxpayer, applicant, or any
person (individual, partnership, corporation, etc.), connected with, or
alleged to have committed, a possible violation of, or to have incurred
a possible liability for tax or other imposition under, any Federal statute
enforced by TTB.
2. PREPARATION
a. The TTB officer uncovering the potential violation or, in the case
of a transmittal of requested information, the appropriate individual
must complete items 3 through 8 in Part I, as applicable.
b. The approving TTB official must complete the remaining items in
Part I. The approving official is the Director, National Revenue
Center, except that referrals concerning firearms and explosives
matters may be approved by the Supervisor, Firearms and
Ammunition Excise Tax Group. Referrals of FAA Act trade practices
violations to the Advertising, Labeling and Formulation Division and
other Federal agencies will be approved by the Chief, Advertising,
Labeling and Formulation Division. Referrals by the Tax Audit
Division will be approved by the Chief, Tax Audit Division.

b. Copy for NRC or permittee file, when referring potential violations.
c. Copy for the approving official's file, when referring potential
violations.
d. Make additional copies when necessary for:
(1) Advertising, Labeling and Formulation Division, Headquarters
Operations, when referring FAA Act trade practices violations to
State or local agencies.
(2) Advertising, Labeling and Formulation Division, Headquarters
Operations, when referring to State agency returns or
return information under 26 U.S.C. 6103.
4. RESPONSE
a. ACTION BY RECIPIENT TTB OFFICE. Complete Part II and
return to the originating office within 10 working days of receipt
of a referral of potential violations. Submit an interim response if
an investigation will continue past the 10-day period, and the final
response upon completion of the investigation.
b. ACTION BY OTHER RECIPIENT AGENCY. Please complete Part
II when a referral of potential violations under your jurisdiction has
been received and returned to the originating office.

3. DISTRIBUTION
a. Original, with any attachments, and the recipient's response copy
to the appropriate TTB official or other agency. If the form is used to
transmit requested information, do not include response copy.

PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. This information collection is used to determine the response of, and value to,
other Federal and State government agencies and bodies of information supplied by TTB. The information is voluntary.
The estimated average burden associated with this collection of information 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 the
Reports Management Officer, Regulations and Rulings Division, Alcohol and Tobacco Tax and Trade Bureau, Washington, D.C. 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 5000.21 (02/2008)