TTB Form 5100.4 "Certificate of Taxpaid Alcohol"

What Is TTB Form 5100.4?

This is a legal form that was released by the U.S. Department of the Treasury - Alcohol and Tobacco Tax and Trade Bureau on November 1, 2015 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2015;
  • The latest available edition released by the U.S. Department of the Treasury - Alcohol and Tobacco Tax and Trade Bureau;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of TTB Form 5100.4 by clicking the link below or browse more documents and templates provided by the U.S. Department of the Treasury - Alcohol and Tobacco Tax and Trade Bureau.

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OMB No. 1513-0131
DEPARTMENT OF THE TREASURY
1. CERTIFICATION
NUMBER
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
CERTIFICATE OF TAXPAID ALCOHOL
Mail this form to: National Revenue Center, 550 Main Street, Suite 8002, Cincinnati, OH 45202.
2. TO: DIRECTOR OF CUSTOMS AND BORDER PROTECTION
PORT OF
SERIAL
TAX PAID AT DISTILLED SPIRITS PLANT
AMOUNT
DATE
NO. OF
PROOF
PROOF
OF TAX
WITHDRAWN
NO.
OPERATED BY
PACKAGE
GALLONS
(b)
(c)
(a)
(d)
(e)
(f)
(g)
3. I certify that no other certificate covering the above-described alcohol has been issued.
This certificate is issued at the request of
to be used at the port of
on account of
drawback on certain flavoring extracts, and/or medicinal or toilet preparations claimed to have been manufactured by
with the use of the above-described alcohol.
4. DATE
5. SIGNATURE OF APPROPRIATE TTB OFFICIAL
PAPERWORK REDUCTION ACT NOTICE
This information collection request is in accordance with the Paperwork Reduction Act of 1995. The purpose of this information collection is for the
protection of Federal excise taxes. The information will be used to determine compliance with requirements governing drawback of tax on the
exportation of nonbeverage commodities. The information required is voluntary.
The estimated average burden associated with this collection of information is 30 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 addressed to the
Reports Management Officer, Regulations and Rulings Division, Alcohol and Tobacco Tax and Trade Bureau, 1310 G Street, NW., Box 12,
Washington, DC 20005.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current, valid OMB
control number.
TTB F 5100.4 (11/2015)
OMB No. 1513-0131
DEPARTMENT OF THE TREASURY
1. CERTIFICATION
NUMBER
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
CERTIFICATE OF TAXPAID ALCOHOL
Mail this form to: National Revenue Center, 550 Main Street, Suite 8002, Cincinnati, OH 45202.
2. TO: DIRECTOR OF CUSTOMS AND BORDER PROTECTION
PORT OF
SERIAL
TAX PAID AT DISTILLED SPIRITS PLANT
AMOUNT
DATE
NO. OF
PROOF
PROOF
OF TAX
WITHDRAWN
NO.
OPERATED BY
PACKAGE
GALLONS
(b)
(c)
(a)
(d)
(e)
(f)
(g)
3. I certify that no other certificate covering the above-described alcohol has been issued.
This certificate is issued at the request of
to be used at the port of
on account of
drawback on certain flavoring extracts, and/or medicinal or toilet preparations claimed to have been manufactured by
with the use of the above-described alcohol.
4. DATE
5. SIGNATURE OF APPROPRIATE TTB OFFICIAL
PAPERWORK REDUCTION ACT NOTICE
This information collection request is in accordance with the Paperwork Reduction Act of 1995. The purpose of this information collection is for the
protection of Federal excise taxes. The information will be used to determine compliance with requirements governing drawback of tax on the
exportation of nonbeverage commodities. The information required is voluntary.
The estimated average burden associated with this collection of information is 30 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 addressed to the
Reports Management Officer, Regulations and Rulings Division, Alcohol and Tobacco Tax and Trade Bureau, 1310 G Street, NW., Box 12,
Washington, DC 20005.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current, valid OMB
control number.
TTB F 5100.4 (11/2015)