Ttb Form 5100.21 - Application, Permit, And Report - Wine And Beer Page 2

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PART IV - REPORT OF PREPAID TAXES

TO COMMONWEALTH INTERNAL REVENUE AGENT

17.

TTB Form 5000.25, with remittance in full for the amount of tax shown in Part III, has been received.

18. DATE

19. DISTRICT DIRECTOR (INVESTIGATIONS), PUERTO RICO OPERATIONS

19a. BY (Signature and official title)

PART V - REPORT OF RELEASE

TO THE SECRETARY OF THE TREASURY OF PUERTO RICO

20.

TTB Form 5000.25, with remittance in full, has been received by the District Director (Investigations), Puerto Rico Operations.

The applicant has on file a good and sufficient bond to cover the taxes described in Part III; therefore, the wine or beer described in Part I has been released for

the purpose indicated.

21. DATE

22. REVENUE AGENT

INSTRUCTIONS

GENERAL. The appli cant must pr epare this fo rm in quintuplicate.

Forms must be serially numbered beginning with “1” each calendar year, and

(b) De ferred Pa yment. If th e ta x i s to be deferred, the ap plicant must ,

running consecutively there after to th e e nd of th e y ear. The serial numbe r

after executing his/her agreement to pay in P art III, deliver all c opies to

must be prefixed by the last two digits of the calendar year, e.g., “10-1.”

the revenue agent.

2. PART I. After executing Part I, the applicant must forward all copies of this

5. PART IV. This part must be dated and signed by the District Director

form to the Secretary of the Treasury of Puerto Rico.

(Investigations), P uerto R ico O perations, if t he t ax is prepaid. H e/She

must then fo rward on e copy of TTB F orm 50 00.25 to the Secretary,

PART II. A fter ex ecuting the per mit in Par t II, the Secretary must re tain

forward one copy of T TB Form 5000.25 and two copies of TTB Form

one copy of this form for his/her files and return the o riginal and remaini ng

5100.21 to th e r evenue a gent, a nd ret ain t he or iginal of TTB Form

copies to the applicant.

5100.21 and TTB Form 5000.25.

4. PART III. (a) Prepayment. If the tax is t o be prepaid, the applicant

6. PART V.

This part m ust b e executed by the r evenue a gent af ter

must s o in dicate in P art I II. On e xecuting P art II I, the applicant mu st

determining that the applicant has proper bond coverage, or in the case

prepare TTB Fo rm 5 000.25, in acc ordance w ith t he i nstructions on th e

of prepayment, o n r eceipt of TTB F 51 00.21 f rom the D istrict D irector

form, and send all copies of t his form and t he original and two copies of

(Investigations), Puerto R ico O perations reporting his/her r eceipt o f

TTB F orm 5 000.25 and remittance in the f ull amount of t he t ax, to the

TTB Form 50 00.25 w ith remi ttance in full. T he rev enue age nt mu st

District Director (Investigations), Puerto Rico Operations, TTB. Ste 310

then forward one copy of this form to the Insular Liquor Bureau and one

Torre Chardon, 350 Carlos Chardon Ave, San Juan, PR 00918.

copy to t he D istrict Revenue A gent (C ommonwealth of Puerto Rico),

deliver one copy to the applicant, and retain one copy each of this form

and TTB Form 5000.25 for his/her files.

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 person to compute the tax

on, taxpay, and withdraw wine or beer. The information is mandatory by statute (26 U.S.C. 7652).

The estimated average burden associated with this collection of information is 1 hour per respondent or recordkeeper, depending on individual circumstances.

Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to the Reports Management Officer,

Regulations and Rulings Division, Alcohol and Tobacco Tax and Trade Bureau, Washington, DC 20220.

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 FORM 5100.21 (04/2010)