Form 5170.7 - Application And Permit To Ship Liquors And Articles Of Puerto Rican Manufacture Taxpaid To The United States - 2015

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OMB No. 1513-0008 (04/30/2015)
1. SERIAL NUMBER
DEPARTMENT OF THE TREASURY - ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
APPLICATION AND PERMIT TO SHIP LIQUORS AND ARTICLES OF PUERTO RICAN
MANUFACTURE TAXPAID TO THE UNITED STATES
PART I - APPLICATION
2. To The Secretary of the Treasury of Puerto Rico
3. Application is made to ship the following liquors or articles of Puerto Rican manufacture to the United States in
(Check one)
bottles and cases
packages
4. DESCRIPTION OF LIQUORS OR ARTICLES
CONTENTS
NO. OF
SIZE OF
NO. OF
RATE
KIND OF
AMOUNT OF
SERIAL NOS.
BOTTLES
BOTTLES
CASES
BRAND NAME
OF
LIQUOR OR
TAX
WINE
PROOF
PROOF
OF PACKAGES
PER
OR
I.R.
ARTICLE
GALS.
CASE
PKGS
TAX
(a)
(f)
(g)
(i)
(b)
(c)
(d)
(e)
(h)
(j)
(k)
8. DATE APPROVED
5. FORMULA
6. FORM NUMBER
7. SERIAL NUMBER (If any)
(If any)
9. TO BE SHIPPED BY (Name of vessel)
10. TO (Port of arrival in U.S.)
11. NAME OF CONSIGNEE
12. ADDRESS OF CONSIGNEE
Under the penalties of perjury, I declare that the taxes equal to the Internal Revenue taxes imposed on like liquors and articles in the United
States have been paid or deferred on such liquors or articles, as prescribed by regulations in 27 CFR Part 26, and that this application and the
statements therein have been examined by me and, to the best of my knowledge and belief, are true, correct, and complete.
13. DATE
14. APPLICANT
15. By (Signature and Capacity)
PART II - CERTIFICATE OF INTERNAL REVENUE AGENT
To The Secretary of the Treasury of Puerto Rico
I hereby certify that taxes equal to the Internal Revenue taxes imposed on like liquors or articles in the United States have been paid or deferred
on the liquors or articles described in Part I, as prescribed by regulations in 27 CFR Part 26.
16. DATE
17. REVENUE AGENT
PART III - PERMIT TO SHIP
Permit is hereby granted to the applicant designated in Item 8 to ship to the United States the liquors or articles described in Part I.
18. DATE
19. SECRETARY
20. BY
PART IV — CERTIFICATE OF AREA PORT DIRECTOR OF CUSTOMS AND BORDER PROTECTION IN PUERTO RICO
I hereby certify that, except as noted in Item 15, the liquors or articles described in Part I were duly inspected and laden for shipment to the
United States.
21. NAME OF VESSEL
22. BOUND FOR PORT OF
23. EXCEPTIONS
TTB FORM 5170.7 (09/2013)

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