Form TTB F 5200.17 TTB F 5200.17 Bond – Drawback of Tax on Tobacco Products, Cigarette Pa

OMB No. 1513-0026 (xx/xx/xxxx)

1. AMOUNT OF BOND

DEPARTMENT OF THE TREASURY

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
BOND -- DRAWBACK OF TAX ON TOBACCO PRODUCTS, CIGARETTE PAPERS, OR TUBES
(See Instructions on Page 2.)

2. PRINCIPAL

3. ADDRESS (Number, Street, City, State, ZIP Code)

4. NAME OF SURETY

5. LOCATION OF PRODUCTS (Number, Street, City, State, ZIP Code)

KNOW ALL MEN BY THESE PRESENTS, That we, the above-named principal and surety, are held and firmly bound unto the United
States of America in the above-named amount, lawful money of the United States, for the payment of which we bind ourselves, our heirs,
executors, administrators, successors, and assigns, jointly and severally, firmly by these presents.
Whereas, the said principal makes claim, as identified below, for allowance of drawback of Internal Revenue tax paid on tobacco products,
cigarette papers, or cigarette tubes, subject to drawback of tax under Title 26 United States Code.
IDENTIFICATION OF CLAIM

AMOUNT

DATE

LOCATION OF DIRECTOR,
NATIONAL REVENUE CENTER, ALCOHOL
AND TOBACCO TAX AND TRADE
BUREAU, WITH WHOM FILED

KIND OF ARTICLES

TO BE SHIPPED TO
(Name and Address)

NOW, THEREFORE, if the said articles or any part thereof, be not relanded at any port or place within the United States, and if the claimant
or his legal representative must produce, as required by the applicable regulations, evidence satisfactory to the Director, National Revenue
Center that the said articles have been landed at some port without the jurisdiction of the Internal Revenue laws of the United States, or that
after clearance from the United States the same were lost (otherwise than by theft), then this obligation must be void; otherwise, it must
remain in full force and effect.

Witness our hands and seals this
Signed, sealed, and delivered in the presence of-

day of

, 20

.
(SEAL)
(SEAL)
(SEAL)
(SEAL)

TTB F 5200.17 (11/2018)

Page 1 of 2

DIRECTOR, NATIONAL REVENUE CENTER
I approve the foregoing bond, which has been executed in due form and in compliance with laws and regulations.
6. SIGNATURE OF DIRECTOR, NATIONAL REVENUE CENTER, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

7. DATE APPROVED

INSTRUCTIONS
1.

This bond must be filed in duplicate with the Director, National Revenue
Center, Alcohol and Tobacco Tax and Trade Bureau, 550 Main Street,
Ste. 8002, Cincinnati, OH 45202-5215 for each claim for drawback filed
under 27 CFR Part 44.

2.

The bond may be given with corporate surety authorized to act as surety by
the Secretary of the Treasury, or by the deposit of transferable bonds or
notes of the United States. The United States Code (6 U.S.C. 15) provides
that "the phrase 'bonds or notes of the United States' shall be deemed * * *
to mean any public debt obligations of the United States and any bonds,
notes, or other obligations which are unconditionally guaranteed as to both
interest and principal by the United States.”

3.

If any alteration or erasure is made on this bond before it is executed, the
principal and the surety must incorporate in the bond a statement specifically
identifying the nature of the change. If any alteration or erasure is made on
this bond after it is executed, the consent of all parties thereto must be written
in the bond.

(c) If the principal is a corporation, the corporate name must be typed or
written and must be followed by the word "by" and the signature and the
title of the officer of the corporation who has been authorized to act in its
behalf, or the signature of the empowered attorney-in-fact. If the
corporation has a corporate seal, the signature for the principal must be
attested under corporate seal. If the corporation has no corporate seal,
that fact must be stated following the name of the corporation and in such
case, the signature of the person executing the bond for the corporate
principal must be affixed in the presence of two persons who must sign
the bond as witnesses.
(d) The name of the corporate surety must be typed or written and must be
immediately followed by the word ''by" and the signature and the title of
the officer of the corporation who has been authorized to sign, or the
signature of an empowered attorney-in-fact. The signature for the
surety must be attested under corporate seal.
7.

If the bond is signed by an attorney-in-fact for the principal or by one of the
members for a partnership or association, or by an officer for a corporation,
the authorization for the person to sign (authenticated power of attorney,
resolution of the board of directors, except of the bylaws, or other document)
must be filed with the bond, unless such authorization has been previously
filed with the Director, National Revenue Center in which event a statement
to such effect must be attached to the bond.

4.

The principal must be identified by stating the full name, if an individual; by
stating the firm name and the full name of each partner or member, if a
partnership or association; or, if a corporation, by stating the corporate
name, the name of the State under the laws of which it is organized, and the
address of the principal office.

5.

The amount of the bond must not be not less than the amount of tax for which
drawback is claimed.

8.

After this bond is approved by the Director, National Revenue Center, a copy
will be returned to the principal.

6.

The bond must be executed in duplicate by the principal and by the surety in
the following manner:

9.

All correspondence about the filing of this form or any subsequent action,
including termination affecting this bond, should be addressed to the
Director, National Revenue Center, Alcohol and Tobacco Tax and Trade
Bureau, with whom the bond is filed.

(a) If the principal is an individual, either he/she or his/her authorized
attorney-in-fact must sign the bond. The signature must be affixed in the
presence of two persons who must sign the bond as witnesses.
(b) If the principal is a partnership or an association, the firm name must be
typed or written and must be followed by the word "by" and the signatures
of all partners or members, or the signature of any partner or member
authorized to sign in behalf of the firm, or the signature of an empowered
attorney-in-fact. Each signature must be affixed in the presence of two
persons who must sign the bond as witnesses.

PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. This bond is required to obtain drawback of
taxes on articles which are exported. This information is required to obtain a benefit by 26 U.S.C. 5706.
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 addressed to the Report Management Officer, Regulations and Rulings Division, Alcohol
and Tobacco Tax and Trade Bureau, 1310 G Street, NW., Box 12, Washington, DC 20005.
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 5200.17 (11/2018)