Form Ttb F 5000.24 - Excise Tax Return - 2012

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OMB No. 1513-0083 (06/30/2012)
1. SERIAL NUMBER
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)
EXCISE TAX RETURN
3. AMOUNT OF PAYMENT
(Prepare in duplicate – See instructions below)
$
2. FORM OF PAYMENT
CHECK
MONEY ORDER
EFT
OTHER (Specify)
PLEASE MAKE CHECKS OR MONEY ORDERS
NOTE:
PAYABLE TO THE ALCOHOL AND TOBACCO TAX AND
4. RETURN COVERS (Check one)
TRADE BUREAU (SHOW EMPLOYER IDENTIFICATION
BEGINNING
NUMBER ON ALL CHECKS OR MONEY ORDERS). IF
PREPAYMENT
PERIOD
YOU SEND A CHECK, SEE PAPER CHECK CONVERSION
ENDING
NOTICE BELOW.
5. DATE PRODUCTS TO BE REMOVED (For Prepayment Returns Only)
For TTB Use Only
6. EMPLOYER IDENTIFICATION NUMBER
7. PLANT, REGISTRY, OR PERMIT NUMBER
TAX
$
PENALTY
8. NAME AND ADDRESS OF TAXPAYER (Include ZIP Code)
INTEREST
TOTAL
$
EXAMINED BY:
DATE EXAMINED:
CALCULATION OF TAX DUE (Before making entries on lines 18 – 21, complete Schedules A and B)
PRODUCT
AMOUNT OF TAX
(a)
(b)
$
9.
DISTILLED SPIRITS
10. WINE
11. BEER
12. CIGARS
13. CIGARETTES
14. CIGARETTE PAPERS AND/OR CIGARETTE TUBES
15. CHEWING TOBACCO AND/OR SNUFF
16. PIPE TOBACCO AND/OR ROLL-YOUR-OWN TOBACCO
$
17. TOTAL TAX LIABILITY (Total of lines 9-16)
18. ADJUSTMENTS INCREASING AMOUNT DUE (From line 29)
$
19. GROSS AMOUNT DUE (Line 17 plus line 18)
20. ADJUSTMENTS DECREASING AMOUNT DUE (From line 34)
$
21. AMOUNT TO BE PAID WITH THIS RETURN (Line 19 minus line 20)
Under penalties of perjury, I declare that I have examined this return (including any accompanying explanations, statements, schedules, and forms) and
to the best of my knowledge and belief it is true, correct, and includes all transactions and tax liabilities required by law or regulations to be reported.
22. DATE
23. SIGNATURE
24. TITLE
SCHEDULE A – ADJUSTMENTS INCREASING AMOUNT DUE
AMOUNT OF ADJUSTMENTS
EXPLANATION OF INDIVIDUAL ERRORS OR TRANSACTIONS
(b) TAX
(c) INTEREST
(d) PENALTY
(a)
$
$
25.
26.
27.
$
$
$
28. SUBTOTALS OF COLUMNS (b), (c), and (d)
$
29. TOTAL ADJUSTMENTS INCREASING AMOUNT DUE (Line 28, Col (b) + (c) + (d)) Enter here and on line 18.
SCHEDULE B – ADJUSTMENTS DECREASING AMOUNT DUE
AMOUNT OF ADJUSTMENTS
EXPLANATION OF INDIVIDUAL ERRORS OR TRANSACTIONS
(b) TAX
(c) INTEREST
(a)
$
$
30.
31.
32.
$
$
33. SUBTOTALS OF COLUMNS (b) and (c)
$
34. TOTAL ADJUSTMENTS DECREASING AMOUNT DUE (Line 33, Col (b) + (c)) Enter here and on line 20.
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.
TTB F 5000.24 (04/2012)

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