Form TTB F 5520.2 TTB F 5520.2 Annual Report of Concentrate manufacturer

Form Approved: OMB No. 1513-0022 (10/31/2011)

1 . RE GIS T R Y NUM B E R

DEPARTMENT OF THE TREASURY — ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

ANNUAL REPORT OF CONCENTRATE MANUFACTURER

2 . CA LE N DA R YE A R

(See Paperwork Reduction Act Notice on next page)

INSTRUCTIONS
This
form must be prepared annually (in duplicate). The original must be forwarded not later than 15
T
days
after the close of the calendar year for which rendered, to the Director, National Revenue Center,
1
a
Alcohol
and Tobacco Tax and Trade Bureau, 550 Main St, Ste 8002, Cincinnati, OH 45202-5215.
3. NAME OF MANUFACTURER

The
T remaining copy must be maintained on or convenient to the concentrate plant and available for
inspection
by TTB officers. Upon permanent discontinuance of the business submit this annual
i
r
report
not later than 15 days after such discontinuance and mark the report "Final Report."

4. ADDRESS OF M A NUFACTURER (Number, Street, City or Town, State, ZIP Code)

5. SUMMARY OF CONCENTRATE BY KIND AND ALCOHOLIC CONTENT (Wine Gallons)
KIND (Specify)

ITEM
_

FOR
REMOVAL TO
BONDED
WINE
CELLAR
(a)

KIND (Specify)

HIGH
ALL
PROOF
OTHER
CONCENTRATE CONCENTRATE
(b)

(c)

FOR
REMOVAL TO
BONDED
WINE
CELLAR
(d)

ALL
HIGH
OTHER
PROOF
CONCENTRATE
CONCENTRATE
(e)

(f)

KIND (Specify)

KIND (Specify)

FOR
REMOVAL TO
HIGH
ALL
BONDED
PROOF
OTHER
WINE
CONCENTRATE CONCENTRATE
CELLAR
(g)
(h)
(i)

FOR
REMOVAL TO
BONDED
WINE
CELLAR
(j)

ON HAND
(1) BEGINNING

OF YEAR

(2) PRODUCED
(3)
TO BE ACCOUNTED

(4) FOR
(total lines 1 thru 3)
(5) USED ON

PREMISES
REMOVED

(6) (rendered unfit for
beverage use)
REMOVED

(7) (w ithout treatment)
REMOVED TO

(8) BONDED WINE
CELLAR

(9)
(10) ON HAND END
OF YEAR

ACCOUNTED

(11) FOR (total lines 5
thru 10)
Under penalties of perjury, I declare that I have examined
this report and, to the best of my knowledge and belief, it
is true, correct, and complete.
TTB Form 5520.2 (01/2009)

6. DATE

7. PROPRIETOR

8. BY (Signature and Title)

ALL
HIGH
OTHER
PROOF
CONCENTRATE CONCENTRATE
(k)

(l)

PAPERWORK REDUCTION ACT NOTICE
The purpose of this information is to account for all concentrates manufactured, removed, or
treated so as to be unfit for beverage use. The information is required to verify that alcohol is
not being diverted thereby jeopardizing tax revenues. The information is mandatory by statute.
(26 U.S.C. 5511)

The estimated average burden associated with this collection of information is 20 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 addressed to the Reports Management Officer,
Regulation 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 Form 5520.2 (01/2009)