Form TTB F 5120.24 TTB F 5120.24 Drawback on Wines Exported

OMB No. 1513-0016 (xx/xx/xxxx)
1. SERIAL NUMBER (begin with “1” each
Jan 1)

DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

DRAWBACK ON WINES EXPORTED
(See instructions below)
(NRC USE ONLY)

PART I - NOTICE
2. TO DIRECTOR, NRC

Director, National Revenue Center / Alcohol and Tobacco Tax and Trade Bureau
550 Main St., Ste 8002
CincinnatI, OH 45202-5215

The undersigned gives notice of the shipment of wines manufactured, bottled, or packaged in the United States CLAIM NUMBER
on which drawback of the internal revenue tax paid or determined is claimed.
3. EXPORTER - NAME AND ADDRESS (Number, Street, City, State, Zip Code)
4. NUMBER1 DATE RECEIVED
TTB F 2639 or TTB F 5620.5
FILED WITH CLAIM NO.2

5. EMPLOYER IDENTIFICATION NUMBER
6. PURPOSE
OF
SHIPMENT
(Make
applicable
entries)
7. CONSIGNED
TO OR IN
CARE OF
(Make
applicable
entries)

TRANSFER TO
SHIPMENT FOR
FOREIGN TRADE
EXPORT TO ARMED
FORCES OF THE U.S. ZONE
EXPORTATION TO (Name of foreign port and country)

(Number)

USE AS SUPPLIES ON

AIRCRAFT3

A VESSEL3

AMOUNT CLAIMED
$

(Location)

AMOUNT REJECTED
$
AMOUNT APPROVED

$
CLAIMS CLERK

PORT DIRECTOR OF CUSTOMS AT PORT OF
TRANSPORTATION
OFFICER

(Name)
(Number)

CUSTOMS OFFICER IN
CHARGE OF FOREIGN
TRADE ZONE
10. DESCRIPTION OF WINE SHIPPED
KIND
OF
WINE

NUMBER
OF
PACKAGES

(a)

(b)

CASES
BOTTLES
NUMBER in case size
(c)

(d)

(e)

SERIAL NUMBERS OF
CONTAINERS OR CASES4
(f)

(Location)

8. NAME OF DOMESTIC
CARRIER

(Location)

9. NAME OF EXPORT CARRIER

ALCOL.
CONTENT

TOTAL
WINE
GALLONS

(g)

(h)

DRAWBACK
RATE PER WINE
GALLON
(i)

PART II - CLAIM
The wines described in Part I have been removed for the purpose stated, and are not to be brought back or relanded within 11. AMOUNT CLAIMED
the limits of the United States. The kind, quantity, and description of the wines stated in Part I is correct, and I am
$
justly entitled to drawback of the tax in the amount claimed herein. Internal Revenue tax equal to such amount has been
12. I REQUEST DRAWBACK
paid or determined as provided by law and regulations. No other claim for allowance of drawback has been made under 26
ALLOWED TO BE PAID
U.S.C. 5062(b), or Section 309 of the Tariff Act of 1930, as amended, on these wines or any part thereof. Under penalties of
BY
perjury, I declare that I have examined Part I hereof, and this claim, and to the best of my knowledge and belief the
statements herein and in Part I, are true, correct, and complete.
CREDIT
CHECK
13. DATE
14. EXPORTER
14a. BY (Signature and Title)

1
Insert, as applicable, plant number of distilled spirits plant, registry number of bonded
wine cellar or taxpaid wine bottling house, or number of the wholesale liquor dealers
permit issued under the Federal Alcohol Administration Act.
2
Complete only for consolidated claims; show serial number of last claim tabulated.
3
State whether a (a) vessel or aircraft operated by the United States; (b) vessel or aircraft
engaged in foreign trade, or in trade between the United States and any of its
possesions, or between Hawaii or Alaska and any other part of the United States;
TTB F 5120.24 (8/2006)
TTB F 5120.24 (8/2006)

(c)
(c) vessel
vessel of
of the
the United
United States
States engaged
engaged in
in trade
trade between
between Atlantic
Atlantic
and
employed
in
and Pacific
Pacific ports
ports of
of the
the United
United States;
States; (d)
(selvessel
employed
in
country
and ports
ofthe
call,wd)
or ifveshaling
a whalingbusiness.
vessel, location
country of
(1)registry,
the fisheries:
or (2)
Sh
of
If aircraft,
show also
ofshow
airlinealso
andname
country
of operations.
vessel, location
of operations.
If name
aircraft,
of of
airline and
country of registry of aircraft. 4Show filing date when
registry
of aircraft.
4
Show
filing date
date has
when
useauthorized
of such date
has of
been
authorized
use
of such
been
in lieu
serial
numbersino
lieu of serial numbers on cases.

PART III-CUSTOMS OFFICER'S CERTIFICATION OF LADING OR DEPOSIT

I hereby certify that the wines described in Part I were found as described, except as noted in Item 20, and that the wines were -VESSEL (Name)
AIRCRAFT (Name, symbols, number)
15. LADEN FOR
TRUCK (State license)
RAILROAD CAR (Number)
USE AS
SUPPLIES
ON BOARD
17. NUMBER
18. SHIPPED TO (frontier port)
19. SERIAL NUMBER OF SEALS USED
16 RECEIVED IN
FOREIGN
TRADE ZONE
20.
INSPECTION DISCLOSED
DISCREPANCIES
NO
NO EVIDENCE OF
OR SHORT SHIPMENT
DISCREPANCY
TAMPERING
AS FOLLOWS:
23. SIGNATURE AND TITLE OF CUSTOMS OFFICER
21. DATE
22. PORT
EXPORT

24. FRONTIER PORT

PART IV - CUSTOMS OFFICER’S PORT REPORT OF THROUGH SHIPMENT AT FRONTIER PORT
25. DATE RECEIVED
26. INSPECTION DISCLOSED :
NO EVIDENCE OF TAMPERING

SEALS INTACT

SEALS BROKEN

(See Item 27)

27. NATURE AND EXTENT OF DISCREPANCIES, TRANSSHIPMENT, RESEALING, ETC.
28. The exporting conveyance noted in Item 15, bearing the wines described in Item 10,
with exceptions as noted in items 20 and 27, cleared from this port for the port of
29. DATE
30 .SIGNATURE AND TITLE OF CUSTOMS OFFICER

FOREIGN PORT

PART V - CERTIFICATE OF CLEARANCE OR USE
31. THE EXPORTING CONVEYANCE BEARING THE WINES DESCRIBED IN ITEM 10, WITH EXCEPTIONS AS NOTED ABOVE -BOUND FOR (Foreign port)
CLEARED FROM THE PORT OF
ON (Date)
33. DATE
34. SIGNATURE OF PORT DIRECTOR OF
32. THE WINE HAS BEEN USED AS SUPPLIES ON THE
CUSTOMS
FISHING VESSEL OR AIRCRAFT IDENTIFIED ABOVE,
AND THE EVIDENCE OF SUCH USE HAS BEEN
RECEIVED.
PART VI - CERTIFICATE RECEIPT BY ARMED FORCES OFFICER
The wine described in Part I, with exceptions as noted in item 36, were received for export to the armed forces of the United States. The wines will not be
shipped for consumption or use in any place subject to the application of the Internal Revenue laws of the United States.
35. DATE
36. DISCREPANCIES
37. SIGNATURE

38. RANK

39. TITLE

INSTRUCTIONS
1. GENERAL. Under 27 CFR 28.212 and 28.214 persons qualified as proprietors of
distilled spirits plants, bonded wine cellars, or taxpaid wine bottling houses, or holding
wholesale liquor dealer permits issued under the Federal Alcohol Adminstration Act, are
authorized to file claims on Form 5120.24 for allowance of drawback of Internal Revenue
taxes.
2. NUMBER OF COPIES. Prepare this form in quadruplicate, except prepare a fifth copy,
marked “Consignee’s Copy,” where the wine is for use on an aircraft.
3. INSTRUCTIONS TO EXPORTER. Complete Part I and execute Part II. If you are a
proprietor of a bonded wine cellar, you may elect (item 12) to have a drawback allowance
paid either by check, or by credit (Form 2639) which can be claimed on a subsequent
tax return on Form 5000.24; all other claimants should check the box designated “Check”. On
shipments of the wine, forward the original and one copy of this form to the official designated in
Item 7, forward one copy to the Director, NRC, Alcohol and Tobacco Tax and Trade Bureau
at the address shown in item 2, and retain a copy in your files. If a “Consignee’s Copy” has
been prepared (see instruction 2), forward it to the airline company at the airport.
4. ACTION BY CUSTOMS. (a) Shipment for Direct Exportation, or Use on Vessels Other
Than Fishing Vessels. After inspection of lading, the Customs officer must execute Part IV,
forward the original to the Director, NRC, Alcohol and Tobacco Tax and Trade Bureau at the
address shown in item 2, and retain the copy for his files. (b) Use on Aircraft and Fishing
Vessels. After inspection of lading, the Customs officer must execute Part III on both copies

and forward them to the Port Director of Customs. The Port Director, on receipt of the
required ”Certificates of Use” (for aircraft) or Customs Form 5125 (for fishing vessels), must
execute Part V, forward the original to the Director, NRC, Alcohol and Tobacco Tax and Trade
Bureau at the address shown in item 2, and retain the copy for his/her files. (c) Lading at interior
Port For Exportation Through Frontier Port. On completion of lading, the Customs officer
will affix the seals, then execute Part III on both copies and forward them to the Port
Director of Customs at the interior port of lading for forwarding to the Customs officer at the
frontier port. That officer, when satisfied that the shipment has been exported, must execute
Part IV on both copies and return them to the Port Director of Customs at the interior port.
The Port Director will then execute Part V, forward the original to the Director, NRC,
Alcohol and Tobacco Tax and Trade Bureau at the address shown in item 2, and retain the
copy for his/her files. (d) Receipt in Foreign Trade Zones. On receipt of the wine, the Customs
officer must execute Part III on both copies, forward the original to the Director, NRC,
Alcohol and Tobacco Tax and Trade Bureau at the address shown in item 2, and retain the
copy for his/her files.
5. ACTION BY ARMED FORCES OFFICER. On receipt of the wines, the officer to whom
consigned (or other authorized supply officer) must execute Part VI on both copies, forward
the original to the Director, NRC, Alcohol and Tobacco Tax and Trade Bureau at the address
shown in item 2, and retain the copy for his/her records.

RETENTION PERIOD: The retention period is three years from the record date or the date
of the last entry required to be made on the record, whichever is later. The appropriate
TTB officer may require records to be kept an additional period not to exceed three years.

PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with Paperwork Reduction Act of 1995. This information collection is used to obtain drawback of taxes on wine exported from the United States. The
information is required to obtain a benefit under 26 U.S.C. 5062. PAPERWORK REDUCTION ACT NOTICE
This
request is in
accordance
with
Paperwork
Reduction
Act of of
1995.
This information
is used
obtain drawback
of taxes on wine
exported
from the United
States. The
The estimated
average
burden
associated
with
this collection
information
is 1 hour collection
and 7 minutes
pertorespondent
or recordkeeper,
depending
on individual
circumstances.
information is required to obtain a benefit under 26 U.S.C. 5062.
Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to the Report Management Officer, Regulations and
Rulings Division, Alcohol and Tobacco Tax and Trade Bureau, Washington, D.C. 20220.
The estimated average burden associated with this collection of information is 1 hour and 7 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 Report Management Officer, Regulations and Rulings Division,
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.
Alcohol and Tobacco Tax and Trade Bureau, Washington, D.C. 20220

TTBagency
F 5120.24
.An
may(7/2006)
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 5120.24 (8/2006)