OMB No. 1513-0093 (12/31/2009)
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)
APPLICATION FOR EXTENSION OF TIME FOR PAYMENT OF TAX
(Please read conditions below before completing form)
TAXPAYER'S NAME (or names in the case of a partnership)
TAXPAYER'S IDENTIFICATION
NUMBER
PLEASE
PRESENT ADDRESS
TYPE
OR
PRINT
CITY, TOWN OR POST OFFICE, STATE, AND ZIP CODE
Director, National Revenue Center, 550 Main St, Ste 8002, Cincinnati, OH 45202-5215.
I request an extension of time from
, to
, in which to pay
(enter due date of return)
(enter requested extension date)
.
tax of $
for tax period ended
, 20
This extension is necessary because (If more space is needed, please attach a separate sheet) .
I am unable to borrow money to pay the tax because:
As evidence of the need for the extension, I am attaching: (1) a statement of assets and liabilities as of the last day of the preceding month
(showing book and market values of assets and whether any securities are listed or unlisted); and (2) an itemized list of receipts and
disbursements for the 3 months before the date the tax is due.
Under penalties of perjury, I declare that I have examined this application, including any accompanying schedules and statements, and to the
best of my knowledge and belief it is true, correct, and complete.
SIGNATURE OF APPLICANT OR APPLICANTS (in the case of a partnership)
(DATE)
THE DIRECTOR, NATIONAL REVENUE CENTER WILL LET YOU KNOW WHETHER THE EXTENSION IS GRANTED OR DENIED. HOWEVER, HE
OR SHE CANNOT CONSIDER AN APPLICATION IF IT IS FILED AFTER THE DUE DATE OF THE RETURN.
FOR TTB USE ONLY
THIS APPLICATION IS:
TAX: $
APPROVED
INTEREST: $
DISAPPROVED FOR THE FOLLOWING REASONS:
TOTAL: $
Y
PLEASE MAKE CHECK PAYABLE TO
Y
ALCOHOL AND TOBACCO TAX AND
TRADE BUREAU BY:
YOU WILL BE RESPONSIBLE FOR FAILURE TO PAY PENALTY PLUS ADDITIONAL INTEREST IF YOU FAIL TO
MAKE PAYMENT WITHIN 10 DAYS FROM THE DATE OF THIS DENIAL.
(Date)
SIGNATURE AND TITLE OF AUTHORIZED TTB OFFICIAL
DATE
TTB F 5600.38 (06/2007)