TTB F 5600.33 Statement of Ultimate Vendor

OMB No. 1513-0128

DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

STATEMENT OF ULTIMATE VENDOR
(For use in claiming credit or refund of overpayment determined under section 6416(b)(2) of the internal Revenue Code.)
The undersigned or the
(Name of ultimate vendor if other than undersigned)

of which the undersigned is

, is the ultimate vendor of the article specified
(Title)

below or on the reverse side hereof. The article was purchased by the ultimate vendor tax-paid and was thereafter
exported, used, sold, or resold (as indicated below or on the reverse side hereof). The ultimate vendor possesses
(Proof of exportation in respect of the article, or a certificate as to use executed by the ultimate purchaser of the article.)

The
(Proof of exportation or certificate)

(1) is retained by the ultimate vendor, (2) will, upon request, be forwarded to
at any time within 3 years from the date
(Name of person who paid tax)

of this statement for use by that person to establish that credit or refund is due in respect of the article, and (3) will
otherwise be held by the ultimate vendor for the required 3-year period. According to the best knowledge and belief of
the undersigned, no statement in respect of the
(Proof of exportation or certificate)

has previously been executed, and the undersigned understands that the fraudulent use of this statement may subject the
undersigned or any other party making such fraudulent use to all applicable criminal penalties under the Internal Revenue
Code.
SIGNATURE

PRINTED NAME

DATE

ADDRESS

VENDOR'S
INVOICE

ARTICLES

DATE OF
RESALE

QUANTITY

EXPORTED OR USE MADE
OR
TO BE MADE (Specify)

PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. In some cases, persons who sell firearms or ammunition tax-free use specific
statements to support the tax-free sales. In addition, a specific statement from the ultimate vendor to support claims for certain tax refunds or credits is
required. This form contains all required information for a properly executed statement. This is being provided to promote uniformity among excise
taxpayers and eliminate the need for taxpayers to design their own statements. The information requested is required by Title 27, Code of Federal
Regulations, Part 53.
We estimate the average burden associated with this collection of information is 45 minutes per respondent or recordkeeper, depending on your individual
circumstances. Address your comments concerning the accuracy of this burden estimate and suggestions to reduce this burden to: Reports Management
Officer, Regulations and Rulings Division, Alcohol and Tobacco Tax and Trade Bureau, 1310 G Street, NW, Box 12, Washington, DC 20005.
TTB may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a current, valid OMB control number.
TTB F 5600.33 (07/2017)