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pdfOMB No. 1513-0113 (06/30/2011)
TAX
YEAR
2012
TOB
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
SPECIAL TAX “RENEWAL” REGISTRATION AND RETURN
(TAX PERIOD 7/1/2011 – 6/30/2012) (See separate instruction sheet)
SECTION I – TAXPAYER IDENTIFYING INFORMATION
1. EMPLOYER IDENTIFICATION NUMBER
BUSINESS TELEPHONE
(
)
-
2. OWNERSHIP INFORMATION
(Check One Box Only)
INDIVIDUAL OWNER
PARTNERSHIP
3.
OTHER
CORPORATION
TOBACCO PRODUCTS MANUFACTURERS
AND TOBACCO EXPORT WAREHOUSE
PROPRIETORS (with gross receipts less than
$500,000 for most recent tax year.)
SECTION II – CORRECTIONS TO PREPRINTED TAXPAYER IDENTIFYING INFORMATION
(Complete ONLY if needed, and ONLY for the items requiring changes)
4. NAME (Last, First, Middle) or CORPORATE NAME (if Corporation)
6. MAILING ADDRESS
5. TRADE NAME
7. CITY, STATE, ZIP CODE
9. EMPLOYER IDENTIFICATION NUMBER
8. DATE OF CHANGE (mm/dd/yyyy)
-
-
10. BUSINESS TELEPHONE NUMBER
SECTION III – CHANGE IN OWNERSHIP - STATUS
(Check and complete as applicable)
11.
12.
The person identified above no longer owns the business or is no longer engaged in the operations covered by this special
tax “renewal” registration and return. (Please complete Section V below.)
DATE BUSINESS DISCONTINUED
(mm/dd/yyyy)
I am the new owner of the business location identified above. I commenced business operations on
(mm/dd/yyyy). (Please complete Section II above, and Sections IV and V below. As needed, correct/change the Special
Tax Location Registration information.)
SECTION IV – TAX COMPUTATIONS
(See Enclosed Tax Class Reference Chart)
13.
(a)
TAX CLASS
OFFICIAL
USE ONLY
FF
(b)
TAX
CODE
FP
(c)
NUMBER OF
LOCATIONS
I
(d)
TAX RATE
($)
TOTAL
(e)
TAX DUE
($)
14. TOTAL TAX DUE
IF YOU OWE SPECIAL TAX FOR THIS TAX PERIOD, YOU MUST SUBMIT PAYMENT BY JULY 1, 2011
MAKE CHECK OR MONEY ORDER PAYABLE TO “ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)”, WRITE YOUR EMPLOYER
IDENTIFICATION NUMBER ON THE CHECK AND SEND IT WITH THE RETURN TO SOT TAX, 550 MAIN ST., STE 8002, CINCINNATI, OH 45202
SECTION V – TAXPAYER CERTIFICATION
Under penalties of perjury, I declare that the statements in this return/registration are true and correct to the best of my knowledge and
belief; that this return/registration applies only to the specified business and location or, where the return/registration is for more than
one location, it applies only to the business operations at the locations specified on the attached Special Tax Location Registration
Listing. NOTE: Violation of Title 26, United States Code 7206, with respect to a declaration under penalties of perjury, is punishable
upon conviction by a fine of not more than $100,000 ($500,000 in the case of a corporation) or imprisonment for not more than 3 years,
or both, with the costs of prosecution added thereto.
15. SIGNATURE
TTB F 5630.5R (03/2011)
16. TITLE
17. DATE
Page 1 of 5
OMB No. 1513-0113 (06/30/2011)
TAX
YEAR
2012
TOB
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
SPECIAL TAX LOCATION REGISTRATION LISTING
(RENEWAL BUSINESS – TAX PERIOD 7/1/2011 – 6/30/2012)
INSTRUCTIONS
1. Review and verify that all preprinted business location information is correct.
2. A full street address or rural route description for the actual physical location of the business is required. A post office box number
is unacceptable, and if left uncorrected may delay or prevent registration of the location as required by law.
3. If any preprinted business location information is incorrect, line through the incorrect business location information and clearly print
or type the correct business location information.
4. If a business location is no longer in business, line through all preprinted business location information pertaining to that business
location; print or type the words “OUT OF BUSINESS”; and, show the date business activities ceased at the business location.
5. Enter business location information for new business locations in the space provided below. Please print or type all business
location information entered for each new business locations.
EMPLOYER IDENTIFICATION NUMBER:
─
TTB
TAX
LOCATION CLASS
NUMBER CODE
TTB F 5630.5R (03/2011)
TRADE NAME
LOCATION ADDRESS
Page 2 of 5
BUSINESS
TELEPHONE
NUMBER
CITY,
STATE, ZIP CODE
(
)
-
(
)
-
(
)
-
(
)
-
(
)
-
(
)
-
(
)
-
OMB No. 1513-0113 (06/30/2011)
TAX
YEAR
2012
TOB
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
SPECIAL TAX LOCATION REGISTRATION LISTING
(RENEWAL BUSINESS – TAX PERIOD 7/1/2011 – 6/30/2012)
EMPLOYER IDENTIFICATION NUMBER:
─
TTB
TAX
LOCATION CLASS
NUMBER CODE
TRADE NAME
BUSINESS
TELEPHONE
NUMBER
CITY,
STATE, ZIP CODE
LOCATION ADDRESS
(
)
-
(
)
-
(
)
-
(
)
-
(
)
-
(
)
-
(
)
-
DO NOT WRITE IN THE SPACE BELOW EXCEPT TO ADD A NEW BUSINESS LOCATION
TRADE NAME
BUSINESS TELEPHONE NUMBER
(
LOCATION ADDRESS
TAX CODE
TTB F 5630.5R (03/2011)
)
-
CITY, STATE, ZIP CODE
TAX CLASS
DATE NEW LOCATION STARTED BUSINESS (mm/dd/yyyy)
Page 3 of 5
OMB No. 1513-0113 (06/30/2011)
SUPPLEMENTAL INSTRUCTION SHEET FOR COMPLETING
SPECIAL TAX “Renewal” REGISTRATION AND RETURN, TTB FORM 5630.5R (03/2011)
ATTENTION “PERMITTEES”
If you are no longer engaged in the operations authorized by the Alcohol and Tobacco Tax and Trade Bureau (TTB), and
have complied with all requirements for discontinuance (e.g., disposal of tobacco, filing of final report(s), etc.), you are
authorized to submit your Permit(s) and/or Notices for cancellation with this Special Occupational Tax (SOT) Renewal.
Make sure that you have completed Items 11, 15, 16, and 17 on the front of this form. Such cancellation will not affect
your right to reapply in the future. However, you may not engage in any operations requiring authorization until you have
re-qualified.
If you have a permit, but you ARE NOT CONDUCTING BUSINESS for which you have been issued a permit, you MUST
FILE this tax return and attach a statement saying that you are currently “INACTIVE” and file a new tax return before
conducting any operations in this tax year.
For assistance in disposing of tobacco, or if you need other information regarding documents to be filed, please contact
the TTB National Revenue Center at 1-877-882-3277, or (513) 684-3334 between 8 A.M. and 5 P.M. EST.
1.
Item 1 – Taxpayer Identifying Information – If any
taxpayer identifying information in Block 1 is incorrect,
enter only the corrected information in the appropriate
block in Section II.
5. Check Item 3 only if you are a tobacco products
manufacturer or you are the proprietor of a tobacco
export warehouse, and the gross receipts for your
entire business, from all sources (not just receipts
relating to the activity subject to special occupational
2. Your tax return must contain a valid Employer
tax), was less than $500,000 for the tax year
Identification Number (EIN). A missing or incorrect
immediately preceding this tax year. If your business
EIN will result in a delay in the processing of your special
meets these conditions, you are eligible for a reduced
tax registration and return form, and in the issuance of
tax rate and may compute your tax using the
a special tax stamp. An EIN is a unique number for
appropriate reduced tax rate shown on the enclosed
business entities issued by the Internal Revenue
Tax Class Reference Chart. However, if you are a
Service (IRS). You must have an EIN whether you are
member of a controlled group as defined in section
an individual owner, partnership, corporation, or an
5061(e) (3) of the Internal Revenue Code, you are not
agency of the government. If you do not have an EIN,
eligible for a reduced rate unless the total gross
contact your local IRS office immediately to obtain
receipts for the entire group are less than $500,000.
one. If you submit a special tax registration and return
6. Item 11 – If you have discontinued business
form that does not have an EIN, TTB may assign a
operations, check Item 11 and enter the date of
temporary identification number (beginning with XX) to
allow initial processing of the special tax registration
discontinuance in the space provided and complete
and return form. However, a special tax stamp, TTB
Section V.
Form 5630.6A, will not be issued until you have
7 Item 12 – If you are the new owner of the business,
notified us of the issuance of a valid EIN. If your
check Item 12 and complete Sections II, IV and V.
special tax registration and return form has an XX
Also, correct any errors on the Special Tax “Renewal
number or an incorrect EIN in Item 1, be sure to enter
Registration and Return.
the correct EIN in Item 9.
8. Item 13 – If tax payment is due, the amount shown in
Do not delay the submission of your special tax
Column 13(e), as tax due, is computed by multiplying
registration and return form, and any payment, past
the number of locations, Column 13(c), by the tax rate,
the due date pending the receipt of a valid EIN.
Column 13(d). Add additional tax classes (if
Submit your EIN by separate correspondence after
necessary) in the vacant spaces provided or attach
receipt from the IRS.
additional sheets.
3. Item 2 – Check only one box to describe the type of
9. Item 14 – If tax payment is due, the total tax due is
ownership of the business identified in Item 1.
computed by adding the figures in Column 13(e).
4. Item 3, – Reduced Rate Taxpayers and Exempt
10. If the preprinted information in Section IV is incorrect,
Activities – You must declare your eligibility for a
line through the incorrect items(s) and write in the
reduced rate or special tax exemption each year.
correct information alongside the lined out item(s).
The regular rates are used to compute the
amounts shown as due on the special tax
11. See the enclosed Tax Class Reference Chart for tax
registration and return form.
class and tax rate information.
TTB F 5630.5R (03/2011)
Page 4 of 5
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
OMB No. 1513-0113 (06/30/2011)
TAX CLASS REFERENCE CHART
TAX YEAR 2012
TAX
CLASS
DESCRIPTION
Manufacturer of tobacco products
TAX
RATE
$1,000
Manufacturer of tobacco products – REDUCED*
TOBACCO
PRODUCTS
Manufacturer of cigarette papers and tubes
$500
$1,000
Manufacturer of cigarette papers and tubes – REDUCED*
Proprietor of export warehouse
$500
$1,000
Proprietor of export warehouse – REDUCED*
$500
TAX
CODE
STATUS
91
PAYABLE
95*
PAYABLE
92
PAYABLE
96*
PAYABLE
93
PAYABLE
97*
PAYABLE
See supplemental instructions for explanation of Reduced Rates.
IF YOU NEED FURTHER ASSISTANCE
CONTACT THE NATIONAL REVENUE CENTER
at 1-800-937-8864 or (513) 684-2979
PAPERWORK REDUCTION ACT
This information is used to ensure compliance by taxpayers with P.L. 100-203, Revenue Act of 1987, P.L. 100647, Technical Corrections Act of 1988, and the Internal Revenue laws of the United States. The Alcohol and
Tobacco Tax and Trade Bureau (TTB) uses the information to determine and collect the right amount of tax.
The estimated average burden associated with this collection is 15 minutes per respondent or recordkeeper,
depending on individual circumstances.
Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should
be directed 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 a person is not required
to respond to, a collection of information unless it displays a current, valid OMB control number.
PRIVACY ACT
A Privacy Act Statement required by 5 U.S.C. 552a(e)(3) stating our authority for soliciting and collecting the
information from your check, and explaining the purposes and routine uses which will be made of your check
information, is available at http://www.ttb.gov/pdf/notice-of-system-records.pdf, or call toll free at (877) 8823277 to obtain a copy by mail. Furnishing the check information is voluntary, but a decision not to do so may
require you to make payment by some other method.
Notice to Customers Making Payment by Check: If you send us a check, it will be converted into an
electronic funds transfer (EFT). This means we will copy your check and use the account information on it to
electronically debit your account for the amount of the check. The debit from your account will usually occur
within 24 hours, and will be shown on your regular account statement. You will not receive your original
check back. We will destroy your original check, but we will keep the copy of it. If the EFT cannot be
processed for technical reasons, you authorize us to process the copy in place of your original check. If the
EFT cannot be completed because of insufficient funds, we may try to make the transfer up to 2 times.
TTB F 5630.5R (03/2011)
Page 5 of 5
| File Type | application/pdf |
| File Title | OMB NO |
| Author | TTB |
| File Modified | 2011-03-15 |
| File Created | 2011-02-24 |