Form TTB F 5150.22 TTB F 5150.22 Application for an Industrial Alcohol User Permit

OMB No. 1513-0028 (8/31/2014)

DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)

APPLICATION FOR AN INDUSTRIAL ALCOHOL USER PERMIT
(Prepare in duplicate. See instructions below.)
1. INDUSTRIAL USE NUMBER (Leave blank for original 2. SERIAL NUMBER
application)

3. DATE OF APPLICATION

4. APPLICATION MADE BY (Give full name and principal business address 5. ADDRESS WHERE ALCOHOL WILL BE USED IF DIFFERENT
FROM ITEM 4
and the State in which incorporated, if applicable.)

E-MAIL ADDRESS (OPTIONAL)
BUSINESS PHONE#:

EIN:

PLANT PHONE#:

6. APPLICATION IS MADE TO: (Check applicable box(es))
a.
DEAL IN SPECIALLY DENATURED SPIRITS (Alcohol, Rum)
b.

USE SPECIALLY DENATURED SPIRITS (Alcohol, Rum)

7. ESTIMATED ANNUAL WITHDRAWALS

c.

USE TAX-FREE ALCOHOL

d.

RECOVER (SDA, Articles, Tax-free Alcohol)

8. TYPE OF ORGANIZATION

a.

Wine gallons of specially denatured spirits

a.

Sole Proprietor

c.

Corporation

b.

Proof gallons of tax-free spirits

b.

Partnership

d.

State or Local Governmental Agencies
(Including hospitals, universities, etc.)

9. PURPOSE FOR WHICH SPIRITS WILL BE USED

10. PURPOSE FOR WHICH THIS APPLICATION IS FILED

11. TRADE NAMES ( Identify the office where they are registered.)

12. LIST OF EQUIPMENT USED IN RECOVERY PROCESS (Include serial number, kind, capacity, name and address of manufacturer and owner of
distilling apparatus, and state the intended use.)

13. CONDITIONS
I fully understand that any permits that are issued pursuant to this application are subject to the following conditions:
a. That there are no false statements in this application; that all employees while on the permit premises will conform to all of the laws of the United
States relating to the manufacture, taxation, and control of and traffic in intoxicating liquors, and all regulations pursuant to these laws, in force
now or later; that I will pay the tax, with interest and penalties, on all alcohol diverted while being transported to me, and on all alcohol withdrawn,
transported, used, or disposed of by me in violation of the laws and regulations, in force now or later; and that all persons interested in the
business to be conducted under this permit are, under the laws and regulations, qualified to receive the privileges applied for.
b. That all data, written statements, evidence, affidavits, and other documents submitted in support of this application will be deemed to be a part of
this application, and any permit issued is conditioned on this provision.
c. That specially denatured and tax-free spirits will be stored and secured in accordance with the requirements of 27 CFR, Parts 20 and 22.
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and
complete.
15. SIGNATURE OF AUTHORIZED PERSON
14. NAME AND TITLE OF AUTHORIZED PERSON (Type or Print)

TTB F 5150.22 (09/2013)

INSTRUCTIONS
I

GENERAL INSTRUCTIONS
1.

This application is filed in duplicate with the Director, National Revenue
Center, Alcohol and Tobacco Tax and Trade Bureau, 550 Main St,
Ste 8002, Cincinnati, OH 45202-5215.

2.

The purpose is to obtain or amend an Industrial Alcohol User Permit
(TTB F 5150.9) to withdraw, deal in, or use specially denatured
alcohol under 27 CFR 20.41, or to use tax-free alcohol under
27 CFR 22.41.

3.

4.

Submit supporting organizational documents as required under
27 CFR 20.45 and 22.45, and personnel questionnaires on all officers,
directors, and stockholders, if applicable.
An amended application is required when any information on the
Permit (TTB F 5150.9) is changed and whenever required to do so
by the Director, National Revenue Center. Letter notices
sequentially numbered may be filed in some instances.

5.

Tax-free alcohol, in its original or recovered state, cannot be used or
sold for beverage purposes, food products, or in any preparation
used in beverage or food products. A permittee who uses tax-free
alcohol in any manner prohibited by 27 CFR Part 22 will become
liable for the tax on the alcohol.

6.

State and local government agencies, including hospitals and
universities, are exempt from the requirement of posting bond.
Applicants who qualify for this exemption must submit proof of the
right to exemption. A State, political subdivision, or the District of
Columbia may specify in the application that it desires a single
permit authorizing the withdrawal and use of specially denatured or
tax-free spirits in a number of institutions under its control. Show the
method of distribution and accounting for the specially denatured or taxfree spirits to be withdrawn on a separate attachment marked “Supplemental application for an Industrial Alcohol User Permit to TTB F 5150.22."
SPECIFIC INSTRUCTIONS

ITEM 1.

The National Revenue Center will issue a dealer or user permit
number on original applications. Use this assigned number on
future applications filed for an amendment of the permit.

ITEM 2.

Use number one (1) on original applications. Each subsequent
application filed to amend your Permit (TTB F 5150.9) will be
given the next consecutive serial number.

ITEM 3.

Use the current date.

ITEM 4.

Enter the name and complete address of the sole owner, all
partners in a partnership, or the name of a corporation.
Corporations will enter their principal address and give the
name of the State under which they are incorporated, such as
“Incorporated in the State of Delaware.” Include a daytime
telephone number in the event we must contact you.

ITEM 5.

Complete this section when the address of the premises is
different from that in item 4.

ITEM 6.

Check the applicable box(es).

ITEM 7.

Show specially denatured alcohol in wine gallons and tax-free
alcohol in proof gallons.

ITEM 8.

Indicate the type of ownership.

ITEM 9.

Be specific in usages such as dealer, manufacturer of
cosmetics, external medicines, fuels, mouthwashes, inks,
solvents, laboratory analyses, clinical use, treatment of
patients, compounding medicines for the use of hospital
patients, preserving specimens, etc.

ITEM 10. Use to file an original application or to amend an existing
permit. Specify what is being amended, such as change of
address, change of estimated annual usage, etc.
ITEM 11. Trade name registration with County Clerk, Secretary of State,
or other agency is required in some States. Give the name of
the office where the trade name is registered, if applicable.
ITEM 12. Equipment listed should include processing tanks, storage
tanks, equipment for recovery, restoration, or redenaturation of
denatured spirits. Use a separate sheet if the space in item 12
is inadequate.
ITEM 13. These conditions show under what provisions your permit may
be used. It is your responsibility to be aware of and comply with
the laws and regulations under which your permit may be issued.
ITEM 14. An approved Power of Attorney (TTB F 5000.8) must be filed
as authority to represent the sole owner, partnership, or
corporation when the authorization, by title or name, is not
contained in any type of agreement, Articles of Incorporation,
By-Laws, or a resolution.
ITEM 15. Signature of the applicant or person authorized to represent
the applicant.

PRIVACY ACT INFORMATION
The following information is provided pursuant to Section 3 of the Privacy Act of 1974 (5 U.S.C. 552a(3)):
1.

AUTHORITY. Solicitation of this information is made pursuant to 26 U.S.C. 5271. Disclosure of this information by the applicant is mandatory if the
applicant wishes to obtain a permit to use alcohol free of tax.

2.

PURPOSE. To identify the applicant, to identify the location where the applicant will use the tax free alcohol, and to determine the eligibility of the applicant to
obtain a permit to use alcohol free of tax.

3.

ROUTINE USES. The information will be used by TTB to make the determinations set forth in paragraph 2. In addition, the information may be disclosed to other
Federal, State, foreign, and local law enforcement, and regulatory agency personnel to verify information on the application where such disclosure would not be
prohibited by law. The information may further be disclosed to the Justice Department if it appears that the furnishing of false information may constitute a violation
of Federal law. Finally, the information may be disclosed to members of the public in order to verify the information on the application where such disclosure is not
prohibited by law.

4.

EFFECTS OF NOT SUPPLYING REQUESTED INFORMATION. Failure to supply complete information will delay processing and may result in the denial of the
application.
PAPERWORK REDUCTION ACT NOTICE

This request is in accordance with the Paperwork Reduction Act of 1995. The information collection is used to determine the eligibility of the applicant to engage in
certain operations, to determine location and extent of operations, and to determine whether the operations will be in conformity with Federal laws and regulations. The
information requested is required to obtain or retain a benefit and is mandatory by statute (26 U.S.C. 5271).
The estimated average burden associated with this collection of information is 1 hour per respondent or recordkeeper, depending on individual circumstances. Comments
concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addresssed to the Reports Management Officer, Regulations and
Ruling Division, Alcohol and Tobacco Tax and Trade Bureau, 1310 G Street, NW, Ste. 200-E, 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 5150.22 (092013