Form Ttb F 5640.2 Offer In Compromise Of Liability Incurred Under The Federal Alcohol Administration Act

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OMB No. I5I3-0055 (12/31/2014)
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)
TO:
1. PROPONENT’S NAME AND ADDRESS
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
CRIMINAL
BOTH CIVIL AND CRIMINAL
5. DATE OF VIOLATION
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
REMITTANCE
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.)
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 (05/2009)
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