TTB F 5640.2 Offer in Compromise of Liability Incurred Under the Fede

OMB No. 1513-0055 (xx/xx/xxxx)
DEPARTMENT OF THE TREASURY– ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

OFFER IN COMPROMISE
Of Liability Incurred Under The Federal Alcohol Administration Act, As Amended
(To be filed in duplicate with the Director, National Revenue Center, Alcohol and Tobacco Tax and Trade Bureau)
1. PROPONENT’S NAME AND ADDRESS

TO:

2. DATE

DIRECTOR, NATIONAL REVENUE CENTER
550 MAIN ST
STE 8002
CINCINNATI, OH 45202-5215
The following offer in compromise is submitted to you by the undersigned:
3. CHARGES OF VIOLATION OF THE FEDERAL ALCOHOL ADMINISTRATION ACT, AS AMENDED, HAVE BEEN MADE AGAINST THE
PROPONENT AS FOLLOWS: (State specifically the nature of the pending charges and the sections of law and regulations alleged to have been violated)

4. TYPE OF LIABILITY (Check one)
CIVIL
5. DATE OF VIOLATION

CRIMINAL

BOTH CIVIL AND CRIMINAL

6. LOCATION OF VIOLATION

7. THE ALLEGED VIOLATION WAS DUE TO THE FOLLOWING CAUSE OR CAUSES : (Attach a separate sheet if necessary.)

8. TO SECURE THE RELEASE FROM THE LIABILITY RESULTING FROM THE VIOLATION OR FAILURE ABOVE
SPECIFIED, THE SUM INDICATED IS OFFERED VOLUNTARILY WITH A REQUEST THAT IT BE ACCEPTED IN
COMPROMISE OF THAT LIABILITY. (Make remittance payable to the Alcohol and Tobacco Tax and Trade Bureau.)

REMITTANCE
$

9. THE FOLLOWING FACTS AND REASONS ARE SUBMITTED AS GROUNDS FOR ACCEPTANCE OF THE OFFER. (If space provided is insufficient,
please attach a supplemental affidavit and supporting evidence.)

TTB F 5640.2 (01/2022)

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It is understood that this offer will be considered and acted upon in due course, and that it does not relieve the proponent from the liability
sought to be compromised unless and until the offer is accepted in writing by the Director, National Revenue Center, or a delegated
official, and there has been full compliance with the terms of this offer.
It is also understood that deposit of any remittance into the accounts of the United States Government, pending action on this offer in
compromise, does not constitute acceptance of the terms of this offer.
In making this offer the proponent expressly understands and agrees that the acceptance of the offer will not in any way affect any liability
(civil, forfeiture, or criminal) which he/she may have incurred by reason of violation of Federal laws other than specified in item 3 of this
form, or regulations issued pursuant thereto, whether or not connected with the violations herein sought to be compromised.

10. IF OFFER IS MADE BY AGENT, THE REASON MUST BE STATED IN THIS SPACE

Under penalties of perjury, I declare that I have examined this offer, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete.
12. AGENT’S ADDRESS

11. SIGNATURE OF PROPONENT OR AGENT

PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. This information collection is used by a person who has
incurred liability under the Federal Alcohol Administration Act to tender an offer in compromise in lieu of criminal and/or civil penalties
(27 U.S.C. 207). TTB examines the information to determine whether to accept the offer in compromise. Submission of this information
is required to obtain a benefit.
The estimated average burden associated with this collection is 2 hours per respondent or recordkeeper, depending on individual
circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed
to the Paperwork Reduction Act Officer, Regulations and Rulings Division, Alcohol and Tobacco Tax and Trade Bureau, 1310 G Street,
NW., Box 12, Washington, DC 20005 (please do not mail completed forms to this address).
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.

PRIVACY ACT INFORMATION
The following information is provided pursuant to Section 3 of the Privacy Ac of 1974 (5 U.S.C. 552a(e)(3)).
1. Authority. Solicitation of this information is made pursuant to 27 U.S.C. 207. Disclosure of this information by the proponent is
voluntary.
2. Purpose. To enable TTB to evaluate and act upon the proponent’s proposal for an offer in compromise.
3. Routine Uses. The information will be used by TTB to make the determination 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 form where such a disclosure is not 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 when authorized by statute or regulations.
4. Effect of Not Supplying Information Requested. Failure to supply complete information may prevent TTB from making an informed
judgment regarding the consideration of the proposed offer.
Disclosure of the individual's social security number is voluntary. Under 27 U.S.C. 207, TTB has the authority to solicit this information.
The social security number may be used to verify the individual's identity.

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TTB F 5640.2 (01/2022)