TTB Form 5100.24 "Application for Basic Permit Under the Federal Alcohol Administration Act"

What Is TTB Form 5100.24?

This is a legal form that was released by the U.S. Department of the Treasury - Alcohol and Tobacco Tax and Trade Bureau on August 1, 2018 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2018;
  • 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 5100.24 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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Download TTB Form 5100.24 "Application for Basic Permit Under the Federal Alcohol Administration Act"

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OMB NO. 1513-0018 (10/31/2018)
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)
APPLICATION FOR BASIC PERMIT UNDER THE FEDERAL ALCOHOL ADMINISTRATION ACT
1. FULL NAME AND PREMISES ADDRESS
3. EMPLOYER IDENTIFICATION NUMBER (EIN)
(Social Security number is not acceptable)
4. OPERATING NAME (DBA), if an y
TELEPHONE NUMBER (
)
State in which organized for Corporations and Limited Liability Companies (LLC):
2. MAILING ADDRESS (If different from premises address)
5. LABELING TRADE NAME(S), if an y
6. BUSINESS(ES) TO BE CONDUCTED AT PREMISES ADDRESS (Check applicable boxes)
a.
DISTILLED SPIRITS PLANT (BEVERAGE)
c.
IMPORTING INTO THE UNITED STATES
DISTILLING
DISTILLED SPIRITS
WAREHOUSING AND BOTTLING DISTILLED SPIRITS
WINE
PROCESSING (RECTIFYING) DISTILLED SPIRITS AND WINE
MALT BEVERAGES
b.
BONDED WINE PREMISES
d.
PURCHASING FOR RESALE AT WHOLESALE
PRODUCING AND BLENDING WINE
DISTILLED SPIRITS
BLENDING WINE
WINE
MALT BEVERAGES
or while so engaged, sell, off er, or deliver for sale, contract to sell, or ship in interstate or
reign commerce the alcoholic beverages so distilled,
produced, rectified, blended or bottled, warehoused and bottled, impor ted, or purchased for resale at wholesale.
7. REASON FOR THE APPLICATION (use date format MM/DD/YYYY)
a.
NEW BUSINESS
c.
CHANGE IN OWNERSHIP
Anticipated start date ___________
Date of Change _______________
Name, address, and permit number(s) of predecessor
b.
CHANGE IN CONTROL (Actual or legal)
Submit Basic Permit(s) with this application.
Date of Change ______________
8. OWNER INFORMATION (List sole owner, all general parties, LLC members/managers, corporate officers and directors, and shareholders with more
than 10% voting stock. Each listed person must also furnish the information in Item 9.)
SOURCE OF FUNDS INVESTED
% VOTING/STOCK/INTEREST
INVESTMENT IN
(savings, loans, gift, or specify
% VOTING/STOCK/INTEREST
INVESTMENT IN
SOURCE OF FUND,S INVESTED
NAME
TITLE
TITLE
NAME
(If applicable)
BUSINESS (Item 6)
other & financial institution
(If applicable)
BUSINESS (Item 6)
(savings, loans, gift or specify other)
name, city & state)
IF APPLICANT IS ACTUALLY OR LEGALLY CONTROLLED BY PERSONS OR B SINESSES NOT IDENTIFIED ABOVE, PROVIDE ON A SEPARATE
SHEET INFORMATION (as specified f or Item 9) FOR EACH PERSON OR B SINESS AND STATE THE EXTENT AND MANNER OF THE CONTROL.
BUSINESSES SHOULD INCLUDE THEIR EIN.
9. COMPLETE FOR EACH PERSON LISTED IN ITEM 8.
a. FULL GIVEN NAME
b. DATE AND PL
E OF BIRTH
c. SOCIAL SECURITY OR EMPLO
R
IDENTIFICATION NUMBER
d.
e. OTHER NAMES USED (Maiden name, nicknames, etc.)
MALE
FEMALE
8)
TTB F 5100.24 (08
Page 1 of 2
OMB NO. 1513-0018 (10/31/2018)
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)
APPLICATION FOR BASIC PERMIT UNDER THE FEDERAL ALCOHOL ADMINISTRATION ACT
1. FULL NAME AND PREMISES ADDRESS
3. EMPLOYER IDENTIFICATION NUMBER (EIN)
(Social Security number is not acceptable)
4. OPERATING NAME (DBA), if an y
TELEPHONE NUMBER (
)
State in which organized for Corporations and Limited Liability Companies (LLC):
2. MAILING ADDRESS (If different from premises address)
5. LABELING TRADE NAME(S), if an y
6. BUSINESS(ES) TO BE CONDUCTED AT PREMISES ADDRESS (Check applicable boxes)
a.
DISTILLED SPIRITS PLANT (BEVERAGE)
c.
IMPORTING INTO THE UNITED STATES
DISTILLING
DISTILLED SPIRITS
WAREHOUSING AND BOTTLING DISTILLED SPIRITS
WINE
PROCESSING (RECTIFYING) DISTILLED SPIRITS AND WINE
MALT BEVERAGES
b.
BONDED WINE PREMISES
d.
PURCHASING FOR RESALE AT WHOLESALE
PRODUCING AND BLENDING WINE
DISTILLED SPIRITS
BLENDING WINE
WINE
MALT BEVERAGES
or while so engaged, sell, off er, or deliver for sale, contract to sell, or ship in interstate or
reign commerce the alcoholic beverages so distilled,
produced, rectified, blended or bottled, warehoused and bottled, impor ted, or purchased for resale at wholesale.
7. REASON FOR THE APPLICATION (use date format MM/DD/YYYY)
a.
NEW BUSINESS
c.
CHANGE IN OWNERSHIP
Anticipated start date ___________
Date of Change _______________
Name, address, and permit number(s) of predecessor
b.
CHANGE IN CONTROL (Actual or legal)
Submit Basic Permit(s) with this application.
Date of Change ______________
8. OWNER INFORMATION (List sole owner, all general parties, LLC members/managers, corporate officers and directors, and shareholders with more
than 10% voting stock. Each listed person must also furnish the information in Item 9.)
SOURCE OF FUNDS INVESTED
% VOTING/STOCK/INTEREST
INVESTMENT IN
(savings, loans, gift, or specify
% VOTING/STOCK/INTEREST
INVESTMENT IN
SOURCE OF FUND,S INVESTED
NAME
TITLE
TITLE
NAME
(If applicable)
BUSINESS (Item 6)
other & financial institution
(If applicable)
BUSINESS (Item 6)
(savings, loans, gift or specify other)
name, city & state)
IF APPLICANT IS ACTUALLY OR LEGALLY CONTROLLED BY PERSONS OR B SINESSES NOT IDENTIFIED ABOVE, PROVIDE ON A SEPARATE
SHEET INFORMATION (as specified f or Item 9) FOR EACH PERSON OR B SINESS AND STATE THE EXTENT AND MANNER OF THE CONTROL.
BUSINESSES SHOULD INCLUDE THEIR EIN.
9. COMPLETE FOR EACH PERSON LISTED IN ITEM 8.
a. FULL GIVEN NAME
b. DATE AND PL
E OF BIRTH
c. SOCIAL SECURITY OR EMPLO
R
IDENTIFICATION NUMBER
d.
e. OTHER NAMES USED (Maiden name, nicknames, etc.)
MALE
FEMALE
8)
TTB F 5100.24 (08
Page 1 of 2
a. FULL GIVEN NAME
b. DATE AND PLACE OF BIRTH
c. SOCIAL SECURITY OR EMPLOYER
IDENTIFICATION NUMBER
d.
e. OTHER NAMES USED (Maiden name, nicknames, etc.)
MALE
FEMALE
a. FULL GIVEN NAME
b. DATE AND PLA E OF BIRTH
c. SOCIAL SECURITY OR EMPLO ER
IDENTIFICATION NUMBER
d.
e. OTHER NAMES USED (Maiden name, nicknames, etc.)
MALE
FEMALE
a. FULL GIVEN NAME
b. DATE AND PL
E OF BIRTH
c. SOCIAL SECURITY OR EMPLO ER
IDENTIFICATION NUMBER
d.
e. OTHER NAMES USED (Maiden name, nicknames, etc.)
MALE
FEMALE
a. FULL GIVEN NAME
b. DATE AND PLA E OF BIRTH
c. SOCIAL SECURITY OR EMPLO ER
IDENTIFICATION NUMBER
d.
e. OTHER NAMES USED (Maiden name, nicknames, etc.)
MALE
FEMALE
10. HAS THE APPLICANT OR ANY PERSON LISTED FOR ITEMS 8 OR 9 EVER BEEN DENIED A PERMIT, LICENSE, OR OTHER AUTHORIZATION
TO ENGAGE IN ANY BUSINESS TO MANUFACTURE, DISTRIBUTE, IMPORT, SELL, OR USE ALCOHOL PRODUCTS (beverage or nonbeverage)
BY ANY GOVERNMENT AGENCY (Federal, State, local, or foreign) OR HAD SUCH PERMIT, LICENSE, OR OTHER AUTHORIZATION REVOKED,
SUSPENDED, OR OTHERWISE TERMINATED?
YES. State details of each event on a separate sheet.
NO
11. HAS THE APPLICANT OR ANY PERSON LISTED FOR ITEMS 8 OR 9 EVER BEEN ARRESTED FOR, CHARGED WITH, OR CONVICTED OF ANY
CRIME UNDER FEDERAL, STATE, OR FOREIGN LAWS other than traffic violations or convictions that are not felonies under Federal or State law.
YES. State details of each event on a separate sheet.
NO
TTB MAY REQUIRE additional information to process this application. If you are applying for a basic permit to operate a distilled spirits plant or
bonded wine premises, you must also file additional forms and information required under the Internal Revenue Code. OPERATION WITHOUT A
PERMIT. Criminal and administrative actions may be taken against persons engaged in a business listed in Item 6 of this form if it is n t conducted
pursuant to an FAA Act basic permit.
APPLICANT'S AFFIRMATION. Under penalties of perjury, I declare that I have examined this application, including accompanying s atements, and
to the best of my knowledge and belief, it is true, correct, and complete. The applicant must immediately notify the TTB official with whom this applica-
tion is filed of any change in ownership, management, or control of the applicant (in the case of a corporation, any change in the officers, directors, or
persons holding 10 percent or more of the corporate stock). The business for which this application is made does not violate the law of the State in
which the business will be conducted. In addition, if this application is approved, the applicant will conduct operations within a reasonable period of
time and maintain such operations in conformity with Federal law.
14. DATE
12. APPLICANT'S SIGNATURE (Sole owner, partner, corporate
13. TITLE OF PERSON SIGNING
officer, LLC member or manager, or if designated agent, submit
TTB F 5000.8)
(optional) :
15. E-MAIL (INTERNET) ADDRESS
TTB F 5100.24 (08
8)
Page 2 of 2
INSTRUCTIONS
1. GENERAL. You must file this application if you want a permit under
Location of
Send to:
the Federal Alcohol Administration Act (FAA Act) to engage in the
Business
TTB
business of:
Ste. 310 Torre Chardon,
787-766-5584
PUERTO RICO
350 Carlos Chardon
Ave.
· Producing or processing distilled spirits or wine includes for
San Juan, PR 00918-21244
nonindustrial use.
1-877-882-3277
ALL OTHER STATES
550 Main Street, Suite 8002
· Importing into the United States, or wholesaling, alcoholic
Cincinnati, OH 45202
beverages.
3. LABEL APPROVALS FOR BOTTLED ALCOHOLIC BEVERAGES.
Nonindustrial use of distilled spirits or wines includes all beverage
Bottlers, packagers, and importers should have TTB approved label
purposes or uses in preparing foods or drinks. Wholesaling under
certificates (TTB F 5100.31). A label approval is required to sell,
the FAA Act means purchasing alcoholic beverages for resale at
ship, or deliver for sale or shipment, or to otherwise introduce in
wholesale. The FAA Act defines alcoholic beverages as distilled
interstate or foreign commerce, alcoholic beverages. Also, a label
spirits, wine, or malt beverages including any fermented cereal
approval allows importers to release specific imported alcoholic
beverages which have an alcohol content of not less than
percent.
1/2
beverages from Customs' custody. For label approvals contact TTB,
Advertising, Labeling and Formulation Division, Washington, DC
2. COMPLETING AND FILING THIS APPLICATION.
20220,
(202-
). TTB does not approve certificates until
you have the appropriate FAA Act basic permit. You can submit
· Please type or print and complete all items.
draft labels (for example, mockups) to TTB for review before printing
· Write "not applicable" in any item requesting information that does
the labels. Trade name approval on your FAA Act basic permit does
not apply to your business.
not constitute approval as a brand name for labeling purposes.
· Items 8 through 11: If this information is on file with TTB, state
“On file under (name and TTB permit or registry number or type of
4.
. If you
a retail or wholesale dealer and
pending application) ."
deal in beer, wine or distilled spirits, file TTB F 5630.5d, Alcohol Dealer
· If you need additional room, use a separate sheet.
Registration. SPECIAL TAX FOR RETAIL AND WHOLESALE DEALERS
· If your producing or processing operations will be in Puerto Rico,
HAS BEEN REPEALED, NO TAX PAYMENT DUE. You do not file this
contact the Director, Puerto Rico Operations, for additional
form when your business only involves the importation or sale of
requirements.
fermented cereal beverages which have an alcoholic content of less
· Send this form in duplicate to the appropriate TTB (Alcohol and
than
percent or where your business is only in Puerto Rico.
1/2
Tobacco Tax and Trade Bureau ) office.
5. EMPLOYER IDENTIFICATION NUMBER. You need to have this
number for your business even if you do not have any employees.
To obtain an EIN, file Form SS-4 with the Internal Revenue Service.
PRIVACY ACT INFORMATION
1. AUTHORITY. Solicitation of information on TTB F 5100.24 is made pursuant to 27 U.S.C. Section 204(c). Disclosure of this information by the
applicant is mandatory if the applicant wishes to obtain a basic permit under the Federal Alcohol Administration Act.
2. PURPOSES. To identify the applicant , the location of the premises , and to determine the eligibility of the applicant to obt in a basic permit.
3. ROUTINE USES. The information will be used by TTB to make deteminations set forth in paragraph 2 above. Where such disclosure is not
prohibited, TTB officers may disclose this information to other Federal, State, foreign, and local law enforcement and regulatory agency personnel
to verify information on the application, and for enforcement of the laws of such other agency. The information may be disclosed to the Justice
Department if the application appears to be false or misleading. TTB officers may disclose the information to individuals to verify information on
the application where such disclosure is not prohibited.
4. EFFECTS OF NOT SUPPLYING INFORMATION REQUESTED. TTB may delay or deny the issuance of the FAA Act basic permit where
information is not complete or missing.
5. DISCLOSURE OF EMPLOYER IDENTIFICATION NUMBER AND SOCIAL SECURITY NUMBER. You do not have to supply these numbers.
These numbers are used to identify an individual or business. If you do not supply the numbers, your application may be delaye .
PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction of 1995. The information collection is used to determine the eligib lity of the applicant
to engage in certain operations, to determine the location and extent of operations, and to determine whether the operations wi l be in conformity
with Federal laws and regulations. The information requested is required to obtain or retain a benefit and is mandatory by sta ute (27 U.S.C. 203
and 204 (c)).
The estimated average burden associated with this collection of information is 1 hour and 45 minutes per respondent depending
individual
circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be add essed to
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 displa s a current, valid
OMB control number.
TTB F 5100.24 ( 8
8)
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