Form TTB F 5030.6 TTB F 5030.6 Authorization to Furnish Financial Information and Certi

OMB No. 1513-0004 (10/31/2012)

DEPARTMENT OF THE TREASURY-ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
AUTHORIZATION TO FURNISH FINANCIAL INFORMATION
AND
CERTIFICATE OF COMPLIANCE
(Right to Financial Privacy Act of 1978)
SECTION A: CUSTOMER AUTHORIZATION (12 U.S.C. 3404) TO BE COMPLETED BY CUSTOMER

having read the explanation of my rights below on this form, hereby
I,
authorize the following financial institution to disclose the financial records specified below, and any and all information pertaining to those financial
records to the Alcohol and Tobacco Tax and Trade Bureau.
NAME OF FINANCIAL INSTITUTION AND PERSON TO CONTACT (IF KNOWN)

CITY, STATE, AND ZIP CODE

STREET ADDRESS

CHECKING ACCOUNT NUMBER AND NAME ON THE ACCOUNT

SAVINGS ACCOUNT NUMBER AND NAME ON THE ACCOUNT

LOAN NUMBER AND NAME(S) APPEARING ON THE LOAN

OTHER (SPECIFY)

.
PURPOSE FOR WHICH DISCLOSURE IS NECESSARY

I understand that this authorization may be revoked by me in writing at any time before my records, as described above, are disclosed and that this
authorization is valid for no more than three (3) months from the date of my signature.
DATE
SIGNATURE OF CUSTOMER

ADDRESS OF CUSTOMER

SECTION B: CERTIFICATE OF COMPLIANCE BY TTB OFFICIAL

(12 U.S.C. 3403(b))
DATE OF REQUEST

NAME OF FINANCIAL INSTITUTION OFFICIAL AND TITLE

I hereby certify that the applicable provisions of the Right to Financial Privacy Act of 1978, 12 U.S.C. 3401-3422, have been complied with and the good faith reliance upon this
certificate relieves your institution and its employees and agents of any possible liability to the customer in connection with the disclosure of these financial records.

the

SIGNATURE OF TTB OFFIC IAL

ADDRESS

NAME AND TITLE OF TTB OFFICIAL

TELEPHONE NUMBER (Including Area Code)

TTB F 5030.6 (08/2008)

INSTRUCTIONS
If you have any questions about your rights under this law or about how to consent to the release of your financial records, you rnay contact the Alcohol
and Tobacco Tax and Trade Bureau (TTB), Director, National Revenue Center, 550 Main St, Ste 8002, Cincinnati, OH 45202-5215.

1. Section A must be completed by the customer in triplicate and returned to TTB.
2. Section B must be completed by the TTB officer conducting the financial record check.
3. Distribution:

a. First copy (with Section B completed) to the financial institution.
b. Second copy (with Section B completed) filed with the report of audit/investigative report.
c. Third copy (without Section B completed) to the customer.

STATEMENT OF CUSTOMER RIGHTS
UNDER THE
RIGHT TO FINANCIAL PRIVACY ACT OF 1978

Federal law protects the privacy of your financial records. Before
banks, savings and loan associations, credit unions, credit card issuers,
or other financial institutions may give financial information about you to
a Federal agency, certain procedures must be followed.
CONSENT TO FINANCIAL RECORDS
You may be asked to consent to make your financial records
available to the Government. You may withhold your consent, and your
consent is not required as a condition of doing business with any financial institution. If you give your consent, it can be revoked in writing at
any time befor e your records are disclosed. Further more, an y consent
you give is effect ive for only three months, and yo ur financial institution
must keep a record of the instances in which it discloses your financial
information.
WITHOUT YOUR CONSENT
Without your consent, a Federal agency that wants to see your financial
records ma y do so ordinarily only by means of a lawful subpoena, summons, formal written request, or search warrant for that purpose.
Generally, the Federal agency must give you advance notice of its
request for your records explaining why the information is being sought
and telling you how to object in court. The Fed eral agenc y mus t also
send you copies of court documents to be prepared by you with instructions for fil ling them out. While these procedures w ill be kept as simple
as possible, you may want to consult with an attor ney before making a
challenge to a Federal agency’s request.

EXCEPTIONS
In some circumstances, a Federal agency may obtain financial
information about you without advance notice or your consent. In most
of these cases, the Federal agency will be required to go to court to get
permission to obtain y our records without giving y ou notice before
hand. In these instances, the court will make the Government show that
its investigation and request for your records are proper.
When the reason for the delay of notice no longer exists, you will
usually be notified that your records were obtained.
Generally, the Internal Revenue Service will continue to get record s
pursuant to its existing procedures authorized by the Int ernal Revenue
Code rather than under the Right to Financial Privacy Act.
TRANSFER OF INFORMATION
Generally, a Federal agency which obtains your financial records is
prohibited from t ransferring them to another Federal agenc y, unl ess it
certifies in w riting that the transfer is proper and sends a notice to you
that your records have been sent to another agency.
PENALTIES
If a Federal agency or financial institution violates the Right to
Financial Privacy Act, you may sue for damages or to seek compliance
with the law. If you w in, you may be repaid y our attorne y’s fees and
costs.

PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. This information collection is issued by TTB to determine if the applicant is
eligible to receive an alcohol or a tobacco permit. The information is required to obtain a benefit.
The estimated average burden associated with this collection of information 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 addressed to the 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.

TTB F 5030.6 (08/2008)