Form TTB F 5520.3 TTB F 5520.3 Registration of Volatile Fruit-Flavor Concentrate Plant

DEPARTMENT OF THE TREASURY

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

REGISTRATION OF VOLATILE FRUIT - FLAVOR CONCENTRATE PLANT
(PREPARE IN DUPLICATE. SEE INSTRUCTIONS BELOW)

2. DATE

PART I — APPLICATION
3. DIRECTOR, NATIONAL REVENUE CENTER, ALCOHOL AND TOBACCO TAX AND
TO TRADE BUREAU, 550 MAIN ST, STE 8002, CINCINNATI, OH 45202-5215
5. APPLICANTS NAME AND PRINCIPAL BUSINESS ADDRESS
(Number and street, city, State and ZIP Code. If rural address, show
county, name or number of highway, and approximate distance and
direction from applicant's post office)

7. PURPOSE FOR WHICH FILED:

ORIGINAL REGISTRATION

OMB No. 1513-0006
1. SERIAL NUMBER (Number in sequence starting
with "1" for original registration. Leave blank for new plant)

4. REGISTRY NUMBER

6. PLANT ADDRESS (If different from business address. Enter in
same detail as asked for in item 5)

CHANGES AFTER ORIGINAL ESTABLISHMENT (Explain)

OTHER (Specify)

8. INFORMATION REGARDING PROPRIETORSHIP (State whether sole proprietorship, partnership, association, corporation, etc, and furnish
information regarding business organization as required by 27 CFR Part 18) (see instruction 3 below)

9. DESCRIPTION OF STILLS (List separately each still and condenser by serial number, kind, capacity in wine gallons of distillate per hour, and
intended use)

UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE EXAMINED THIS APPLICATION, INCLUDING THE DOCUMENTS
SUBMITTED IN SUPPORT HEREOF OR INCORPORATED HEREIN BY REFERENCE, AND TO THE BEST OF MY KNOWLEDGE
AND BELIEF IT IS TRUE, CORRECT, AND COMPLETE.
10. SIGNATURE

11. TITLE

REMARKS

PART II — REGISTRATION
EFFECTIVE DATE

Approved for registration effective as of date Indicated.

SIGNATURE OF DIRECTOR, NATIONAL REVENUE CENTER, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

TTB F 5520.3 (12/2014)

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DATE

OMB No. 1513-0006

INSTRUCTIONS
1.

If any of the information specified above is already on file with the
Director, National Revenue Center, in connection with another
establishment under the same ownership, such information may, if
accurate and complete, be made a part of this application if the
applicant makes a definitive reference thereto in item 8 and shows
the name and identifying number of the establishment for which
he/she submitted the information.

Submit each application, in duplicate, to the Director, National
Revenue Center, Alcohol and Tobacco Tax and Trade
Bureau, 550 Main St, Ste 8002, Cincinnati, OH 45202-5215,
the application consists of this form and all papers and
documents required by the instructions on the form, or by 27
CFR Part 18 to be furnished as part of the application.

2. Information required by the various items may be furnished on

letter size paper attached to the form. Each sheet must identify
the applicant, this form and the serial number thereof, and the
number and title of the item being reported.

4. When a change occurs which affects the accuracy or

completeness of any information or document furnished in
connection with registration of the plant, submit an amended
application to the Director, National Revenue Center, as prescribed
in 27 CFR Part 18. Such application may be in skeleton form. Items
which are correctly set forth in prior applications and unchanged
may be incorporated in the amended application by reference.
Such incorporation by reference is made by entering for such item
in the space provided therefore the statement "No change since
filing form 5520.3 Ser. No.
" (insert serial number).

3. As to item 8, include as applicable:
(a) Extracts from the articles of incorporation, or from the

minutes of meetings of the board of directors. authorizing the
incumbents of certain offices, or other persons, to sign for the
corporation;
(b) Names and addresses of the officers and directors;

5. When so instructed by the Director, National Revenue Center,

applicants are required to furnish as part of the application such additional information as may be necessary for the Director,
National Revenue Center to determine whether the application
should be approved.

(c) Names and addresses of the 10 persons having the largest

ownership or other interest in the corporation, or other legal
entity, and the nature and amount of the stockholding or other
interest of each, whether such interest appears in the name of
the interested party or in the name of another for him/her;

6. In the case of a partnership, the application must be signed by all

partners, or by a partner duly authorized to sign on behalf of the
firm, or by a duly authorized attorney-in-fact. In the case of a
corporation, the application must be executed in the corporate
name, followed by the signature and capacity of the person duly
authorized to act on its behalf.

(d) In the case of an individual owner or a partnership, the

name and address of every person interested in the concentrate plant, whether such interest appears in the name of the
interested party or in the name of another for him/her.

PRIVACY ACT INFORMATION
The following information is provided pursuant to Section 3 of the Privacy Act of 1974 (5 U.S.C. 552a(e)(3))
1. AUTHORITY. Solicitation of this information is made pursuant to 26 U.S.C. 5511(3). Disclosure of this information by the
applicant is mandatory if the applicant wishes to register WKH volatile fruit flavor plant.
2. PURPOSE. To identify the applicant, the location, the capacity of the premises, the capacity of the plant, and to determine
the eligibility of the applicant to register the plant.
3. ROUTINE USES. The information will be used by TTB to make determinations set forth in paragraph 2. In addition, the information
may be disclosed to other regulatory agency personnel to verify information on the form where such 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 in order to verify the
information on the form when such disclosure is not prohibited by law.
4. EFFECTS OF NOT SUPPLYING INFORMATION REQUESTED Failure to supply complete information will delay
processing and may result in the denial of your application.

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 location and extent of operations, and to determine whether
the operations will be in conformity with Federal law and regulations. The information requested is required to obtain or retain a
benefit, and is mandatory by statute (26 USC 5511). The individual must apply to seek and 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 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 5520.3 (12/2014)

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