Form TTB F 5110.25 Application for Operating Permit Under 26 U.s.c. 5171(D)

Form TTB F5110.25 is a U.S. Department of the Treasury - Alcohol and Tobacco Tax and Trade Bureau form also known as the "Application For Operating Permit Under 26 U.s.c. 5171(d)". The latest edition of the form was released in September 1, 2013 and is available for digital filing.

Download a PDF version of the Form TTB F5110.25 down below or find it on U.S. Department of the Treasury - Alcohol and Tobacco Tax and Trade Bureau Forms website.

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OMB No. 1513-0040 (04/30/2015)
Form Approved: OMB No. 1513-0040 (12/31/2008)
1. Date
2. Plant No.
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
APPLICATION FOR OPERATING PERMIT
UNDER 26 U.S.C. 5171(d)
(File in duplicate) See Paperwork Reduction Act Notice Below
3. NAME AND PRINCIPAL BUSINESS ADDRESS OF APPLICANT
4. PLANT ADDRESS
(If different from principal business addresses)
(Number, Street, City or Town, County, State, ZIP Code)
5. APPLICATION IS HEREBY MADE FOR AN OPERATING PERMIT UNDER 26 U.S.C. 5171(d) TO ENGAGE IN THE FOLLOWING OPERATIONS:
DISTILLING FOR INDUSTRIAL USE
BOTTLING OR PACKAGING OF
MANUFACTURING ARTICLES
SPIRITS FOR INDUSTRIAL USE
DENATURING SPIRITS
WAREHOUSING OF SPIRITS (without
OTHER (Specify)
bottling) FOR NON-INDUSTRIAL USE
WAREHOUSING OF SPIRITS FOR
INDUSTRIAL USE
The application consists of this form and all papers and documents filed in connection therewith or incorporated therein by reference by the applicant.
Under the penalties of perjury, I declare that this application for an operating permit, including the documents submitted in support thereof or
incorporated therein by reference, has been examined by me and, to the best of my knowledge and belief, is true, correct, and complete.
6. SIGNATURE
7. TITLE OR STATUS (State whether individual owner, member of firm,
or if officer of corporation, give title)
INSTRUCTIONS
1. Application for an operating permit under 26 U.S .C, 5171( d), must be
a.
Ever been convicted of a felony or misdemeanor under Federal or State
submitted on this form, in duplicate, to the Director, National Revenue Center
law.
(NRC), Alcohol and Tobacco Tax and Trade Bureau, 550 Main St, Ste 8002,
b.
Ever been arrested or charged with any violation of Federal or State
Cincinnati, OH 45202-5215.
law (convictions or arrests or charges for traffic violations need not
be reported if such violations are not felonies).
2. Applicants are required to furnish, in the manner and detail prescribed in
c.
Ever applied for, held, or been connected with a permit, issued under
27 CFR Part 19, the following information:
Federal L aw, to manufacture, distribute, sell, or use spirits or products
containing spirits, whether or not for beverage use, or held any financial
a.
Statement of business organization and of the persons interested in
interests in any business covered by such permit, and , if so, giv e the
the business, supported by the corporate documents, articles of
number and classification of such permit, the period of operation there-
partnership, and/or statement of interest in the business, as required
under, and state in detail whether such permit was ever suspended,
by 27 CFR Part 19 . (Where any statement or document required by
revoked, annulled, or otherwise terminated. (Where any information
this paragraph is on file with the Director, NRC, such statement
required by this subparagraph is on file with the Director, NRC, such
or document may, by incorporation by reference thereto by the
information may, by incorporation by reference thereto by the applicant,
applicant, be made pa rt of the application for an operating permit.)
be made a part of the application for an operating permit.)
b.
List of the trade names to be used in connection with the operations
specified in the application, showing the operation or operations in
4. Applicants, when so instructed by the Director, NRC, are required to furnish
which each trade name w ill be used. If State or local law requires
as part of the application for an operating permit such additional information as
registration of trade names, evidence of such registration must be
may be necessary to the Director, NRC, to determine whether such permit
furnished. If such registration is not required, a statement to that
should be issued.
effect must be furnished.
3. On specific request of the Director, NRC, furnish a statement whether any
of the persons referred to in paragraph 2a, above has:
PRIVACY ACT INFORMATION
The following information is provided pursuant to Section 3 of the
may be disclosed to other Federal, State, foreign and local law en-
Privacy Act of 1974 (5 U.S.C. 552a(e)(3)):
forcement and regulatory agency personnel to veri fy information on
the application where such disclosure is not prohibited by law. The
1. AUTHORITY. Solicitation of this information is made pursuant to
information may further be disclosed to the Justice Depart ment if it
26 U.S.C. 5171(d). Disclosure of this information by the applicant is
appears that the furnishing of false information may constitute a
mandatory if the applicant wishes to obtain an operating permit.
violation of Federal law. Finally, the information may be disclosed to
members of the public in order to verify the information on the appli-
2. PURPOSE. To identify the applicant, to identify the location where
cation where such disclosure is not prohibited by law.
the plant will be located, and to determine t he eligibility of the appli-
cant to obtain an operating permit.
4. EFFECTS OF NOT SUPPLYING INFORMATION REQUESTED.
Failure to supply complete information will delay processing and may
3. ROUTINE USES. The information will be used by TTB to make
result in the denial of the application.
the determination set forth in paragraph 2. In addition, the information
TTB F 5110.25 (09/2013)
OMB No. 1513-0040 (04/30/2015)
Form Approved: OMB No. 1513-0040 (12/31/2008)
1. Date
2. Plant No.
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
APPLICATION FOR OPERATING PERMIT
UNDER 26 U.S.C. 5171(d)
(File in duplicate) See Paperwork Reduction Act Notice Below
3. NAME AND PRINCIPAL BUSINESS ADDRESS OF APPLICANT
4. PLANT ADDRESS
(If different from principal business addresses)
(Number, Street, City or Town, County, State, ZIP Code)
5. APPLICATION IS HEREBY MADE FOR AN OPERATING PERMIT UNDER 26 U.S.C. 5171(d) TO ENGAGE IN THE FOLLOWING OPERATIONS:
DISTILLING FOR INDUSTRIAL USE
BOTTLING OR PACKAGING OF
MANUFACTURING ARTICLES
SPIRITS FOR INDUSTRIAL USE
DENATURING SPIRITS
WAREHOUSING OF SPIRITS (without
OTHER (Specify)
bottling) FOR NON-INDUSTRIAL USE
WAREHOUSING OF SPIRITS FOR
INDUSTRIAL USE
The application consists of this form and all papers and documents filed in connection therewith or incorporated therein by reference by the applicant.
Under the penalties of perjury, I declare that this application for an operating permit, including the documents submitted in support thereof or
incorporated therein by reference, has been examined by me and, to the best of my knowledge and belief, is true, correct, and complete.
6. SIGNATURE
7. TITLE OR STATUS (State whether individual owner, member of firm,
or if officer of corporation, give title)
INSTRUCTIONS
1. Application for an operating permit under 26 U.S .C, 5171( d), must be
a.
Ever been convicted of a felony or misdemeanor under Federal or State
submitted on this form, in duplicate, to the Director, National Revenue Center
law.
(NRC), Alcohol and Tobacco Tax and Trade Bureau, 550 Main St, Ste 8002,
b.
Ever been arrested or charged with any violation of Federal or State
Cincinnati, OH 45202-5215.
law (convictions or arrests or charges for traffic violations need not
be reported if such violations are not felonies).
2. Applicants are required to furnish, in the manner and detail prescribed in
c.
Ever applied for, held, or been connected with a permit, issued under
27 CFR Part 19, the following information:
Federal L aw, to manufacture, distribute, sell, or use spirits or products
containing spirits, whether or not for beverage use, or held any financial
a.
Statement of business organization and of the persons interested in
interests in any business covered by such permit, and , if so, giv e the
the business, supported by the corporate documents, articles of
number and classification of such permit, the period of operation there-
partnership, and/or statement of interest in the business, as required
under, and state in detail whether such permit was ever suspended,
by 27 CFR Part 19 . (Where any statement or document required by
revoked, annulled, or otherwise terminated. (Where any information
this paragraph is on file with the Director, NRC, such statement
required by this subparagraph is on file with the Director, NRC, such
or document may, by incorporation by reference thereto by the
information may, by incorporation by reference thereto by the applicant,
applicant, be made pa rt of the application for an operating permit.)
be made a part of the application for an operating permit.)
b.
List of the trade names to be used in connection with the operations
specified in the application, showing the operation or operations in
4. Applicants, when so instructed by the Director, NRC, are required to furnish
which each trade name w ill be used. If State or local law requires
as part of the application for an operating permit such additional information as
registration of trade names, evidence of such registration must be
may be necessary to the Director, NRC, to determine whether such permit
furnished. If such registration is not required, a statement to that
should be issued.
effect must be furnished.
3. On specific request of the Director, NRC, furnish a statement whether any
of the persons referred to in paragraph 2a, above has:
PRIVACY ACT INFORMATION
The following information is provided pursuant to Section 3 of the
may be disclosed to other Federal, State, foreign and local law en-
Privacy Act of 1974 (5 U.S.C. 552a(e)(3)):
forcement and regulatory agency personnel to veri fy information on
the application where such disclosure is not prohibited by law. The
1. AUTHORITY. Solicitation of this information is made pursuant to
information may further be disclosed to the Justice Depart ment if it
26 U.S.C. 5171(d). Disclosure of this information by the applicant is
appears that the furnishing of false information may constitute a
mandatory if the applicant wishes to obtain an operating permit.
violation of Federal law. Finally, the information may be disclosed to
members of the public in order to verify the information on the appli-
2. PURPOSE. To identify the applicant, to identify the location where
cation where such disclosure is not prohibited by law.
the plant will be located, and to determine t he eligibility of the appli-
cant to obtain an operating permit.
4. EFFECTS OF NOT SUPPLYING INFORMATION REQUESTED.
Failure to supply complete information will delay processing and may
3. ROUTINE USES. The information will be used by TTB to make
result in the denial of the application.
the determination set forth in paragraph 2. In addition, the information
TTB F 5110.25 (09/2013)
PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act 1995. The information collection is used
to determine the eligibility of the applicant to engage in certain operations, to determine location and
extent of operations, and to determine whether the operations will be in conformity with Federal laws and
regulations. The information requested is required to obtain or retain a benefit and is mandatory by
statute (26 U.S.C. 5171).
The estimated average burden associated with this collection of information is 15 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, Washington, DC 20220.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of infor-
mation unless it displays a current, valid OMB control number.
____________________________________________________________________________________
TTB F 5110.25 (09/2013)
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