Form Ttb F 5000.28t09 - Floor Stocks Tax Return - Tobacco Products And Cigarette Papers And Tubes 2009 Page 3
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3PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. The purpose of this information is to
identify taxpayers and the amount of tax due for each tax return. The information is used by the Government
to ensure that the correct tax was determined and paid. This information is mandatory by Public Law 111-3.
The estimated average burden associated with this collection is 45 minutes 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
Procedures Division, Alcohol and Tobacco Tax and Trade Bureau, Washington, DC 20220.
An agency may not conduct or sponsor, a person is not required to respond to, a collection of information
unless it displays a current, valid OMB control number.
NOTICE TO CUSTOMERS MAKING PAYMENT BY CHECK
If you send us a check, it will be converted into an electronic funds transfer (EFT). This means we will copy
your check and use the account information on it to electronically debit your account for the amount of the
check. The debit from your account will usually occur within 24 hours, and will be shown on your regular
account statement.
You will not receive your original check back. We will destroy your original check, but we will keep the copy of
it. If the EFT cannot be processed for technical reasons, you authorize us to process the copy in place of your
original check. If the EFT cannot be completed because of insufficient funds, we may try to make the transfer
up to 2 times.
PRIVACY ACT
A Privacy Act Statement is required by 5 U.S.C. § 552a(e)(3), stating our authority for soliciting and collecting
the information from your personal check, and explaining the purposes and routine uses which will be made of
your check information. Soliciting and collecting your personal check information is carried out under the
authority of Public Law 111-3, Section 701(h), and the purpose of collecting the information is to collect the
2009 Floor Stocks Tax. Routine uses are listed in
Furnishing the check information is voluntary, but a decision not to do so may require you to make payment by
some other method. The information provided in the form is tax return information, and may only be disclosed
under the specific provisions authorizing disclosure contained in 26 U.S.C. 6103. If it is determined that taxes
are owed, failure to provide the information requested may result in civil and/or criminal penalties under the
Internal Revenue Code of 1986.
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TTB F 5000.28T09 (0 /2009)
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