Form Atf F 5630.5 - Special Tax Registration And Return Alcohol And Tobacco Page 2
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2SECTION III - BUSINESS REGISTRATION
10. OWNERSHIP INFORMATION:
INDIVIDUAL OWNER
PARTNERSHIP
CORPORATION
OTHER ( Specify) ____________
(Check One Box Only)
11. OWNERSHIP RESPONSIBILITY: (Read instruction sheet; use a separate sheet of paper if additional space is needed.)
FULL NAME
ADDRESS
POSITION
FULL NAME
ADDRESS
POSITION
FULL NAME
ADDRESS
POSITION
FULL NAME
ADDRESS
POSITION
FULL NAME
ADDRESS
POSITION
12.
GROSS RECEIPTS less than $500,000 (See instructions for reduced rate taxpayers on the attached instruction sheet)
DATE OF CHANGE (mm, dd, yy)
13.
NEW BUSINESS (NOTE: RETAILERS AND WHOLESALERS SHOW DATE ALCOHOLIC
BEVERAGE SALES BEGAN; PRODUCERS, MANUFACTURERS AND USERS SHOW DATE
BUSINESS COMMENCED)
14.
EXISTING BUSINESS WITH CHANGE IN:
DATE OF CHANGE (mm, dd, yy)
(a) NAME/TRADE NAME (Indicate)
(b) ADDRESS (Indicate)
DATE OF CHANGE (mm, dd, yy)
(c) OWNERSHIP (Indicate)
DATE OF CHANGE (mm, dd, yy)
DATE OF CHANGE (mm, dd, yy)
(d) EMPLOYER IDENTIFICATION NUMBER
(OLD:
NEW:
)
(e) BUSINESS TELEPHONE NUMBER
(
)
DATE BUSINESS DISCONTINUED (mm, dd, yy)
15.
DISCONTINUED BUSINESS
PAPERWORK REDUCTION ACT NOTICE
This information is used to ensure compliance by taxpayers of P.L. 100-647, Technical Corrections Act of 1988, and the Internal Revenue Laws of the United
States. ATF uses the information to determine and collect the right amount of tax.
The estimated average burden associated with this collection of information is .8 hours per respondent or recordkeeper, depending on individual circum-
stances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to Reports Management
Officer, Document Services Branch, Bureau of Alcohol, Tobacco and Firearms, Washington, D.C. 20226.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number.
(SEE ATTACHED INSTRUCTION SHEET)
ATF F 5630.5 (10-99)
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