Form FDA 3852 FDA 3852 Report of Tobacco Product Removals Subject to Tax

Form Approved: OMB No. xxxx-xxxx
Expiration Date: xx/xx/201x
(See Burden Statement on page 2)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration
Center for Tobacco Products

Report of Tobacco Product Removals Subject to Tax
for Tobacco Product User Fee Assessments

(Section 919 of FFDCA; Title 21, Code of Federal Regulations, Part 1150)
Return this completed form and copies of supporting
documents (TTB Forms 5210.5 and 5000.24 and
Customs CBP Form 7501, as appropriate) by mail to:

The authority for collecting the following information
is section 301 et seq. of the Federal Food, Drug,
and Cosmetic Act. The information will be used to
assess and collect user fees from tobacco product
domestic manufacturers and importers. Please be
advised that under section 1001 of title 18 anyone
who makes a materially false, fictitious, or fraudulent
statement is subject to criminal penalties.
1. Company Name/Address (including Zip Code)

Center for Tobacco Products,
Food and Drug Administration,
9200 Corporate Boulevard,
Attn: Document Control Center,
Rockville, MD 20850-3229.
Alternate Company Address (if any, for FDA notifications)

2. Contact Person Name

3. TTB Permit Number

4. Telephone Number (including Area Code)

5. Employer Identification Number

6. Email

7. Period of Activity

A. Month: B. Year:
Domestic Taxable Removals
Volume (Number or Pounds)

Taxes (Dollars)

TTB 5210.5
Monthly Manufacturer Report

TTB 5000.24
Excise Tax Return

Imports
Volume (Number or Pounds)

Taxes (Dollars)

Customs CBP 7501
Importer Entry Summary

8. CIGARETTES
A. Line 14
Columns C + D

B. Line 13
Column B

C. Box 31- Monthly Total

D. Box 38 - Monthly Total

B. Line 12
Column B

C. Box 31- Monthly Total

D. Box 38 - Monthly Total

B. Line 15 Column B

C. Box 31- Monthly Total

D. Box 38 - Monthly Total

(Number of Cigarettes)

(Taxes on Cigarettes Only)

9. CIGARS
A. Line 14
Columns A + B

(Number of Cigars)

(Taxes on Cigars Only)

10. SNUFF
A. Line 14
Column F

FORM FDA 3852 (10/12)

(Snuff Only)

(Pounds of Snuff)

Page 1 of 2

(Taxes on Snuff Only)

PSC Publishing Services (301) 443-6740

EF

Report of Tobacco Product Removals Subject to Tax
Domestic Taxable Removals
Volume (Number or Pounds)

Taxes (Dollars)

TTB 5210.5
Monthly Manufacturer Report

TTB 5000.24
Excise Tax Return

Imports
Volume (Number or Pounds)

Taxes (Dollars)

Customs CBP 7501
Importer Entry Summary

11. CHEWING TOBACCO
A. Line 14
Columns E

B. Line 15 Column B

C. Box 31- Monthly Total
(Pounds of Chewing Tobacco)

(Taxes on Chewing Tobacco Only)

B. Line 16 Column B

C. Box 31- Monthly Total

D. Box 38 - Monthly Total (Taxes

(Chewing Tobacco Only)

D. Box 38 - Monthly Total

12. PIPE TOBACCO
A. Line 14
Column G

(Pipe Tobacco Only)

(Pounds of Pipe Tobacco)

on Pipe Tobacco Only)

13. ROLL-YOUR-OWN TOBACCO
A. Line 14
Column H

B. Line 16 Column B

(Roll-Your-Own Tobacco Only)

C. Box 31- Monthly Total

(Pounds of Roll-Your-Own Tobacco)

D. Box 38 - Monthly Total

(Taxes on Roll-Your-Own Tobacco Only)

14. CERTIFICATION
I hereby certify that the information on this form is true and correct, and that I am hereby authorized to submit this form on the company’s behalf.

14A. Signature (Print and Sign)

14B. Title

14C. Date Prepared (mm/dd/yyyy)

This section applies only to requirements of the Paperwork Reduction Act of 1995.
*DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF ADDRESS BELOW.*
The burden time for this collection of information is estimated to average 4 hours per response,
including the time to review instructions, search existing data sources, gather and maintain the data
needed and complete and review the collection of information. Send comments regarding this burden
estimate or any other aspect of this information collection, including suggestions for reducing this
burden, to the following address:
Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer
Paperwork Reduction Act (PRA) Staff
1350 Piccard Drive, Room 400
Rockville, MD 20850
“An agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid OMB number.”

FORM FDA 3852 (10/12)

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