Form Atf 5630.5 - Special Tax Registration And Return Alcohol And Tobacco printable pdf download

Form Atf 5630.5 - Special Tax Registration And Return Alcohol And Tobacco

OMB No. 1512-0472

(06/30/99)

DEPARTMENT

OF THE TREASURY

BUREAU OF ALCOHOL,

TOBACCO

AND FIREARMS

SPECIAL TAX REGISTRATION

AND RETURN

ALCOHOL AND TOBACCO

(Please Read Instructions

on Back Carefully

Before

Completing

This Form)

SECTION I-TAXPAYER

IDENTIFYING

INFORMATION

1. EMPLOYER IDENTIFICATION

NUMBER

2. BUSINESS TELEPHONE NUMBER

(

)

FOR ATF USE ONLY

3. NAME (Last, First, Middle)

CORPORATE

NAME (If Corporation)

4. TRADE NAME

5. MAILING ADDRESS

(Street address or P.O. box number)

6. CITY

STATE

ZIP CODE

ACTUAL LOCATION

(IF DIFFERENT

THAN ABOVE)

9. TAX PERIOD COVERING

(On/y

7. PHYSICAL ADDRESS

OF PRINCIPAL

PLACE OF BUSINESS

(Show street address)

one taxperiod per

form)

FROM:

8. CITY

STATE

,19_

ZIP CODE

MAKE CHECK OR MONEY ORDER PAYABLE TO “BUREAU OF ALCOHOL,

TOBACCO

AND FIREARMS”,

TOTAL TAX DUE $

WRITE YOUR EMPLOYER

IDENTIFICATION

NUMBER ON THE CHECK AND SEND IT WITH THE RETURN

TO BUREAU OF ATF, P.O. BOX 371962, PITTSBURGH,

PA 15250-7962.

Under penalties of perjury, I declare that the statements

in this return/registration

are true and correct to the best of my knowledge

and belief; that this return/

registration applies only to the specified business and location or, where the return/registration

is for more than one location, it applies only to the businesses

at the locations specified on the attached list. Note:

Violation of Title 26, United States Code 7206, is punishable

upon conviction

by a fine of not more than

$100,000 ($500,000

in the case of a corporation)

or imprisonment

for not more than 3 years, or both, with the costs of prosecution

added thereto.

SIGNATURE

TITLE

DATE

Form Atf 5630.5 - Special Tax Registration And Return Alcohol And Tobacco

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