Ttb Form 5100.21 - Application, Permit, And Report - Wine And Beer

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OMB No. 1513-0123 (03/31/2013)
DEPARTMENT OF THE TREASURY - ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
1. SERIAL NO.
APPLICATION, PERMIT, AND REPORT- WINE AND BEER
(Puerto Rico)
(Prepare in quintuplicate. - See instructions below.)
PART I - APPLICATION
TO THE SECRETARY OF THE TREASURY OF PUERTO RICO
Application is hereby made for a permit to compute the tax on, taxpay, and withdraw for shipment to the United States, the following described wine or beer:
2. DESCRIPTION OF WINE OR BEER
QUANTITY
PRODUCED BY
KIND OF
FORMULA
SERIAL NOS. OF
WINE
BEER
LIQUORS
NO.
CONTAINERS
LOCATION
NAME
1
TAXABLE GRADE
WINE
WINE
BBLS
GALLONS
GALLONS
(b)
(c)
(f)
(a)
(d)
(e)
(g)
(h)
(i)
3. TO BE RELEASED FROM PUBLIC
3a. OPERATED BY:
3b. LOCATED AT:
BONDED WAREHOUSE NO.
4. TO BE RELEASED FOR
Direct shipment
Bottling without rectification
Rectification and bottling
Rectification and packaging
Use in manufacture of articles
Use in manufacture of liqueurs, cordials, etc.
5.
I desire to prepay the computed tax
I have on file with the District Director (Investigations), Puerto Rico Operations, Alcohol and Tobacco Tax
before withdrawal of the liquors.
and Trade Bureau a good and sufficient bond on
TTB Form 5120.32
TTB Form 5130.16 and desire
to withdraw the liquors on computation, but before payment, of the tax.
6. DATE
7. NAME OF APPLICANT
7a. BY (Signature and capacity)
PART II - PERMIT TO COMPUTE
TO THE COMMONWEALTH INTERNAL REVENUE AGENT
8. PERMIT IS HEREBY GRANTED TO - THE ABOVE NAMED APPLICANT TO COMPUTE THE TAX ON THE LIQUORS DESCRIBED IN PART I,
AND TO:
Prepay the computed tax.
Defer payment of the computed tax.
9. DATE
10. SECRETARY
10a. BY (Signature and official title)
PART III - COMPUTATION OF TAX AND STATEMENT OF TAX PAYMENT
11.
WINE TAX
12.
BEER TAX
W
INE GALLONS
TAXABLE
RATE OF
AMOUNT
BARRELS
RATE OF TAX
AMOUNT OF TAX
1
GRADE
OF TAX
TAX
(a)
(c)
(d)
(a)
(b)
(c)
(b)
$
$
Total Wine Tax
Total Beer Tax
$
$
2
TO (Check one)
District Director (Investigations), Puerto Rico Operations
Commonwealth Internal Revenue Agent
13. TOTAL AMOUNT OF TAX
Under the penalties of perjury, I declare that I have examined the above computation of tax and, to the best of my
knowledge and belief, this statement of tax liability is true, correct, and accurate.
$
14. CHECK APPLICABLE BOX
TTB Form 5000.25, with remittance in full for the total amount of the above tax, is transmitted herewith.
I agree to pay, as required by law and regulations, the total amount of tax shown in item 13 and I declare, under the penalties of perjury, that
I am not in default in any payment of tax chargeable against my bond,
TTB Form 5120.32,
TTB Form 5130.16, and that such bond is in the
maximum penal sum or is sufficient to cover that amount in addition to all other amounts chargeable against such bond.
15. DATE
16. NAME OF APPLICANT
16a. BY (Signature and capacity)
1
If champagne or other sparkling wine is being withdrawn, insert "Champ.," or, if artificially carbonated wines are being withdrawn, Insert "Art. Carb." For other wines
see 27 CFR 26.93
2
If the computed tax is to be prepaid, check "District Director (Investigations), Puerto Rico Operations;" if the computed tax is to be deferred, check "Revenue Agent."
TTB FORM 5100.21 (04/2010)
PREVIOUS EDITIONS ARE OBSOLETE

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