TTB F 5100.18 Application for Amended Basic Permit under the Federal A

OMB No. 1513-0019 (xx/xx/xxxx)

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

APPLICATION FOR AMENDED BASIC PERMIT UNDER THE FEDERAL ALCOHOL ADMINISTRATION ACT
(See instructions after this page)
1.

NAME OF PERMITTEE

2.

3.

EMPLOYER IDENTIFICATION NUMBER

REASON FOR CHANGE
5.CHANGE CHANGE OPERATIONS ON PERMIT TO

4. CHANGE

OPERATIONS

NAME ON
PERMIT

ADD NEW TRADE NAME(S) (State the purpose for which each trade name will be used. Use of trade name as a brand name on a label
requires additional approval on TTB F 5100.31.)

6.

CHANGE
IN TRADE
NAME(S)

REMOVE TRADE NAME(S)
CHANGE PREMISES ADDRESS TO (Number, street, route, city or town, State, and ZIP Code)

7.
CHANGE
ADDRESS
(ES)

8.

PERMIT NUMBER(S) TO BE AMENDED

CHANGE MAILING ADDRESS TO (Number, street, route, city or town, State, and ZIP Code OR P.O. Box, city or town, State, and ZIP Code)
REMOVE
NAME

CHANGE IN
OFFICER, ADD THE FOLLOWING INDIVIDUAL (Attach separate sheet if adding more than one person)
DIRECTOR,
b. OTHER NAMES USED (include maiden and married) c.
a. FULL GIVEN NAME (no initials)
STOCKMALE
HOLDER
OR
f. PLACE OF BIRTH
INVESTOR d. SOCIAL SECURITY NUMBER OR EMPLOYER e. BIRTH DATE
(See
IDENTIFICATION NUMBER
instruction
1)

h. NUMBER AND TYPE OF SHARES HELD if person holds more
than 10 percent.

g. ARE YOU A U.S. CITIZEN?
YES

FEMALE

NO

i. TITLE WITH APPLICANT'S BUSINESS

j.

k. RESIDENCES OR PRINCIPAL PLACES OF BUSINESS

INVESTMENT IN PERMITTEE’S BUSINESS if more than 10
percent of capital.

(1) NEW

DURING THE PAST 5 YEARS

(2) SOURCE OF FUNDS (examples, savings,
loan, gift).

$

l.

HAS THIS PERSON EVER BEEN ARRESTED FOR, CHARGED WITH, OR CONVICTED OF, ANY CRIME UNDER FEDERAL,
STATE, OR FOREIGN LAWS other than misdemeanor traffic violations or convictions that are not felonies under Federal or State
law?
(State details
details of each
sheet.)
YES State
each event
eventon
onaaseparate
separate
sheet.
NO

m. HAS THIS PERSON EVER BEEN DENIED A PERMIT, LICENSE OR OTHER AUTHORIZATION TO ENGAGE IN ANY BUSINESS TO
MANUFACTURE, DISTRIBUTE, IMPORT, SELL, OR USE ALCOHOL PRODUCTS (beverage or nonbeverage) BY ANY GOVERNMENT
(Federal, State, local , or foreign) AGENCY OR HAD SUCH PERMIT, LICENSE, OR OTHER AUTHORIZATION REVOKED, SUSPENDED
OR OTHERWISE TERMINATED?
YES (State the details on a separate sheet.)

NO

9. ADDITIONAL INFORMATION. TTB may require additional evidence necessary to verify this application.
10. PERMITTEE’S AFFIRMATION Under penalties of perjury, I declare that I have examined this application, including accompanying statements, and
to the best of my knowledge and belief, it is true, correct, and complete. The business for which this permit is granted does not violate the law of the
State in which business will be conducted.
13. TELEPHONE NO.
11. SIGNATURE OF AUTHORIZED INDIVIDUAL
12. TITLE
14. DATE
15. E-MAIL (INTERNET) ADDRESS (optional):
FOR TTB USE ONLY
16. SIGNATURE AND TITLE OF TTB OFFICIAL
TTB F 5100.18 (12/2017)

17. DATE

INSTRUCTIONS
1. GENERAL. File this application if you want to amend your permit under
the Federal Alcohol Administration Act (FAA Act) or to notify the Alcohol
and Tobacco Tax and Trade Bureau (TTB) of a change in the ownership, management, or control. In the case of a corporation, report any
change in the officers, directors, or persons (individual or business)
who own or control more than 10 percent of the voting stock. When a
change results in an actual or legal change in control or a new person
acquires a permittee’s business, file an application for a new permit
(TTB F 5100.24). Neither the filing of this application nor its approval
allows a business to violate State or local laws, such as registration of
trade names and licensing requirements.
2. FILING. Complete all applicable items. Attach your permit to this
application if you are requesting any amendments identified in items 4
through 7. If you need additional room, use a separate sheet. Put your
name, permit number(s), date of application, and the item number(s) on
each separate sheet. File two copies of this form and any attachments
with the appropriate TTB office listed below. Also, contact this office if
you have questions.

Location of
Business on permit

Send to:
TTB

PR

Director, Puerto Rico Operations
Ste 310 Torre Chardon
350 Carlos Chardon Ave
San Juan, PR 00918-2124

787-766-5584

ALL OTHER STATES

TTB, National Revenue Center
550 Main Street, Suite 8002
Cincinnati, OH 45202

1-877-882-3277

Telephone Number

3. INFORMATION ON FILE. You may reference information if you filed it
with a valid TTB permit or an application that is pending with TTB.
Reference the appropriate item(s) of this application. Include the name
of the applicant or the permittee, and the TTB permit number or the type
and date of the application.
4. OPERATIONS WITHOUT AN AMENDED PERMIT. In general, criminal
and administrative actions may be taken against persons operating
without a valid FAA Act permit. Before you conduct any operations with
any change specified in items 4 through 7, you must apply for, and
receive, an approved permit. Immediately notify TTB of any changes
in the ownership or management in a permittee’s business.
5. ITEM 5 -$/&2+2/'($/(55(*,675$7,21. If you move or change
the location of your business complete TTB F 5630.5d, Alcohol Dealer
Registration within 30 days of the change. You do not need a TTB F
5630.5d when your business only involves the importation or sale of
fermented cereal beverages which have an alcoholic content of less
than 1/2 percent or where your business is only in Puerto Rico.
6. ITEM 11 AND 12 - SIGNING THE APPLICATION. If the permittee is an
individual, the indvidual must sign. If the permittee is a corporation, the
president, vice-president, or other principal officer must sign. If the
permittee is a partnership or other unincorporated organization, a
responsible and authorized member or officer having knowledge
of its affairs must sign. If the permittee is a trust or estate, the fiduciary
must sign. If an agent of the permittee signs, file an acceptable power
of attorney (for example TTB F 5000.8) with the appropriate TTB office.
7. APPROVAL. If you complete any of items 4 through 7 and attach your
permit, TTB will send the amended FAA Act permit to you. If you
complete item 8, TTB will return a copy of this application for your files.

PRIVACY ACT INFORMATION
The following information is provided pursuant to Sections 3 and 7(b) of the Privacy Act of 1974:
1. AUTHORITY. Solicitation of information on TTB F 5100.18 is made pursuant to 27 U.S.C. 204(c). Disclosure of this information by the
applicant is mandatory if the applicant wishes to obtain an amended basic permit under the FAA Act.
2. PURPOSES. To identify the permittee; the location of the premises; and to determine the eligibility of the permittee to obtain an amended basic permit.
3. ROUTINE USES. The information will be used by TTB to make determinations set forth in paragraph 2 above where such disclosure is not prohibited.
TTB officers may disclose this information to other Federal, State, foreign, and local law enforcement and regulatory agency personnel to verify
information on the application and for enforcement of the laws of such other agency. The information may be disclosed to the Justice Department if the
application appears to be false or misleading. TTB officers may disclose the information to individuals to verify information on the application where
such disclosure is not prohibited.
4. EFFECTS OF NOT SUPPLYING INFORMATION REQUESTED. TTB may delay or deny the issuance of the FAA Act basic permit where information is
missing or not complete.
5. DISCLOSURE OF EMPLOYER IDENTIFICATION NUMBER AND SOCIAL SECURITY NUMBER. You do not have to supply these numbers. These
numbers are used to identify an individual or business. If you do not supply these numbers, your application may be delayed.
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 the location and extent of operations, and to determine whether the operations will conform to Federal laws
and regulations. This information is required to obtain a benefit and is mandatory by statute (27 U.S.C. 203 and 204(c)).
The estimated average burden associated with this information collection is 30 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, 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 5100.18 (12/2017)