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

Form Approved: OMB No. 0910-0749
Expiration Date: xx/xx/xxxx
(See PRA Statement on page 3)

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)
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.

Food and Drug Administration
Center for Tobacco Products
Document Control Center
Attn: OM, Division of Financial Management, User Fee Team
Building 71, Room G335
10903 New Hampshire Avenue
Silver Spring, MD 20993-0002

Return this completed form and copies of supporting
documents (TTB Forms 5220.6, 5210.5 and 5000.24 and
Customs CBP Form 7501, as appropriate) by mail to:

Fax: 301-595-1429 or 301-595-1430

1. Company Name/Address (including Zip Code)

Email: [email protected]
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:

Privacy Act Notice:
This notice is provided pursuant to the Privacy Act of 1974, 5 U.S.C. 552a. The collection of this information is authorized
by 21 U.S.C. 371, 379, 379e, 379h, 379h-1, 379j, 379j-12, 379j-21, 387s and 393(d)(2); 42 U.S.C. 263b(r)(1); 5 U.S.C. 301
and 552; and 42 U.S.C. 3101. FDA will use the information to assess, collect and process user fee payments and to
facilitate debt collection under the Debt Collection Improvement Act. FDA may disclose information to courts and the
Department of Justice in the context of litigation and requests for legal advice; to other Federal agencies in response to
subpoenas issued by such agencies; to HHS and FDA employees and contractors to perform user fee services; to the
National Archives and Records Administration and General Services Administration for records management inspections; to
the Department of Homeland Security and other Federal agencies and contractors in order to respond to system breaches;
to banks in order to process payment made by credit card; to Dun and Bradstreet to validate submitter contact information,
and to other entities as permitted under the Debt Collection Improvement Act. Furnishing the requested information is
mandatory. Failure to supply the information could prevent FDA from processing user fee payments. Additional detail
regarding FDA's use of information is available online: http://www.fda.gov/RegulatoryInformation/FOI/PrivacyAct/default.htm,
and http://www.fda.gov/AboutFDA/AboutThisWebsite/WebsitePolicies/default.htm

FORM FDA 3852 (4/16)

Page 1 of 3

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

8. CIGARETTES
A. Line 14
Columns C + D

B. Line 13
Column B

C. Box 31 - Monthly Total

D. Box 38 - Monthly Total

(Number of Cigarettes)

(Taxes on Cigarettes Only)

B. Line 12
Column B

C. Box 31 - Monthly Total

D. Box 38 - Monthly Total

(Number of Cigars)

(Taxes on Cigars Only)

B. Line 15 Column B

C. Box 31 - Monthly Total

D. Box 38 - Monthly Total

(Snuff Only)

(Pounds of Snuff)

(Taxes on Snuff Only)

9. CIGARS
A. Line 14
Columns A + B

10. SNUFF
A. Line 14
Column F

11. CHEWING TOBACCO
A. Line 14
Column E

B. Line 15 Column B

C. Box 31 - Monthly Total

D. Box 38 - Monthly Total

(Chewing Tobacco Only)

(Pounds of Chewing Tobacco)

(Taxes on Chewing Tobacco Only)

B. Line 16 Column B

C. Box 31 - Monthly Total

D. Box 38 - Monthly Total

(Pipe Tobacco Only)

(Pounds of Pipe Tobacco)

(Taxes on Pipe Tobacco Only)

12. PIPE TOBACCO
A. Line 14
Column G

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

B. Line 16 Column B

C. Box 31 - Monthly Total

D. Box 38 - Monthly Total

(Roll-Your-Own Tobacco Only)

(Pounds of Roll-Your-Own Tobacco Only)

(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.

14B. Title

14A. Signature (Print and Sign)

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

FORM FDA 3852 (4/16)

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This section applies only to requirements of the Paperwork Reduction Act of 1995.
*DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL 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 Operations
Paperwork Reduction Act (PRA) Staff
[email protected]

FORM FDA 3852 (4/16)

“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.”

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