Form TTB F 5630.5d TTB F 5630.5d Alcohol Dealer Registration - For Use On and After July

OMB NO. 1513-0112 (03/31/2012)
DEPARTMENT OF THE TREASURY

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)

Alcohol Dealer Registration – For Use On and After July 1, 2008
(Please read instructions carefully before completing this form)

SECTION 1 – IDENTIFYING INFORMATION
Complete all fields in section 1 to correctly identify your business
NAME (Last, First, Middle) or CORPORATE NAME (If Corporation)

EMPLOYER IDENTIFICATION NUMBER (See Instructions)

MAILING ADDRESS (Street address or P.O. Box)

SELECT BOX a, b, or c:
a.
NEW BUSINESS
OUT OF BUSINESS
b.

c.

CITY

STATE

ZIP CODE

EXISTING BUSINESS WITH
CHANGE IN: (complete items below)

DATE OF CHANGE, OR OF ENTRY
INTO BUSINESS, OR OF TERMINATION
OF BUSINESS (mm/dd/yyyy)

NAME / TRADE NAME

OWNERSHIP INFO

ADDRESS / LOCATION

EMPLOYER IDENTIFICATION NUMBER

BUSINESS CLASS

(OLD:

-

)

PHONE

(NEW:

-

)

SECTION 2 – BUSINESS CLASS(ES) AND PREMISES LOCATIONS
Enter information below for each business location, using the appropriate class code

DEALER CLASS

SUBCLASS

CLASS CODE

RETAIL DEALER (Anyone who sells, or offers for sale,

Liquors (Distilled Spirits, Wine or Beer)
beverage alcohol products to any person other than a dealer.
Beer Only
Examples are package stores, restaurants, bars, private
clubs, fraternal organizations, grocery stores or supermarkets Liquors (Distilled Spirits, Wine or Beer) – At Large*
which sell such beverages.)
Beer Only – At Large*

WHOLESALE DEALER (Anyone who sells, or offers for
sale, beverage alcohol products to another dealer. An
IMPORTER must register as a wholesaler if he or she sells
beverage alcohol products to other dealers.)

11
12
15

16

Liquors (Distilled Spirits, Wine, or Beer)

31

Beer Only

32

* A retail dealer at large is one whose business requires him to move from place to place, such as a circus or carnival.
CLASS
CODE

TRADE NAME

PREMISES ADDRESS
STREET NUMBER AND NAME

CITY, STATE,
ZIP CODE

TELEPHONE
NUMBER

(

)

(

)

(

)

(

)

(

)

Under penalties of perjury, I declare that the statements in this registration are true and correct to the best of my
knowledge and belief; that this registration applies only to the specified business and location or, where the registration is
for more than one location, it applies only to the businesses at the locations specified on the attached list.
SIGNATURE
TTB F 5630.5d (05/2009)

TITLE

DATE
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OMB NO. 1513-0112 (03/31/2012)

SECTION 3 – OWNERSHIP INFORMATION
INDIVIDUAL OWNER

PARTNERSHIP

CORPORATION

LLC

OTHER (Specify)

FULL NAME

RESIDENCE ADDRESS

POSITION

FULL NAME

RESIDENCE ADDRESS

POSITION

FULL NAME

RESIDENCE ADDRESS

POSITION

FULL NAME

RESIDENCE ADDRESS

POSITION

FULL NAME

RESIDENCE ADDRESS

POSITION

INSTRUCTIONS
GENERAL INSTRUCTIONS

SECTION 2 – PREMISES LOCATIONS

This registration is for use on and after July 1, 2008. If you are
engaged in one or more of the alcohol activities listed on this form, you
are required to file this form before beginning business. If there is a
change in your business, you need to report it on or before the next
July 1 (see CHANGES IN OPERATIONS, below). You may file one
registration to cover several locations or several types of activity
operating under the same Employer Identification Number (EIN).

Enter the requested information in Section 2 for each premises location
even if this repeats the business information listed in Section 1. If you
are reporting a change, enter the date of the change in the appropriate
space in Section 1. If additional sheets are needed, make a copy of
page 1 of this form or enter the requested information on a separate
sheet of paper with your EIN and Company’s name.

NOTE: The special (occupational) tax on producers and marketers of
alcohol beverages was repealed by Section 11125 of Public Law 10959, effective July 1, 2008. However, tax liability and the registration
requirement for periods before that date remain. If you need to file a
delinquent or amended registration for a period through June 30, 2008,
please use TTB Form 5630.5a, Alcohol Special (Occupational) Tax
Registration and Return – For Periods Ending On or Before June 30,
2008.

Please complete the ownership information in Section 3. Supply the
information specified for each individual owner, partner or responsible
person. For a corporation, partnership or association, a responsible
person is anyone with the power to control the management policies or
buying or selling practices pertaining to alcohol. For a corporation,
association, or similar organization, it also means any person owning
10 percent or more of the outstanding stock in the business.

SIGNING YOUR REGISTRATION
This form must be signed by the individual owner, a partner, or, in the
case of a corporation or LLC, an individual authorized to sign on behalf
of the corporation or LLC.
SECTION 1 – IDENTIFYING INFORMATION
Complete Section 1, Identifying Information, as specified on the form.
Your registration must contain a valid Employer Identification Number
(EIN). The EIN is a unique number for business entities issued by the
Internal Revenue Service (IRS). You must have an EIN whether you
are an individual owner, partnership, corporation, LLC, or a
government agency. If you do not have an EIN, contact the Internal
Revenue Service immediately to obtain one. While TTB may assign a
temporary identification number (beginning with XX) to allow initial
processing of a return which lacks an EIN, do not delay submission of
your registration pending receipt of your EIN. If you have not received
a number by the time you file this return, write "number applied for" in
the space for the number.
Submit your EIN by separate
correspondence after receipt from the IRS.

SECTION 3 – OWNERSHIP INFORMATION

CHANGES IN OPERATIONS
If there is a change of your company’s name, trade name, address,
premises location, telephone number, ownership information, type of
business, or EIN, complete TTB F 5630.5d and submit it no later than
the next July 1 after the change. Check the box, Existing Business
with Change(s), complete all fields in Section 1, and complete Sections
2 and 3 as necessary to show any changes there. Upon going out of
business, submit TTB F 5630.5d within 30 days, checking box b in
Section 1. If you are still in business but there are no changes since
your last registration, this form does not need to be submitted.
MAILING INSTRUCTIONS
Please sign and date this registration and mail it to:
Alcohol and Tobacco Tax and Trade Bureau
550 Main Street, Suite 8002
Cincinnati, OH 45202-5215.
CONTACT INFORMATION
For further assistance, contact TTB National Revenue Center at 1-800937-8864 or 1-877-882-3277; or email to [email protected].
Additional information is also available at our Web site, www.ttb.gov.

PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. This information is used to ensure compliance with Section 11125 of Public
Law 109-59, and the Internal Revenue Laws of the United States.
The estimated average burden associated with this collection of information is .8 hour per respondent or record keeper, 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.
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TTB F 5630.5d (05/2009)