Form TTB F 5110.25 TTB F 5110.25 Application for Operating Permit under 26 U.S.C. 5171(d)

Form Approved:
OMB No.
1513-0040
(12/31/2008)
Form Approved:
OMB
No. 1513-0040
(12/31/2008)

DEPARTMENT OF THE TREASURY — ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

1. Date

2. Plant No.

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
(Number, Street, City or Town, County, State, ZIP Code)

4. PLANT ADDRESS
(If different from principal business addresses)

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
SPIRITS FOR INDUSTRIAL USE

MANUFACTURING ARTICLES

DENATURING SPIRITS

WAREHOUSING OF SPIRITS (without
bottling) FOR NON-INDUSTRIAL USE

OTHER (Specify)

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
submitted on this form, in duplicate, to the Director, National Revenue Center
(NRC), Alcohol and Tobacco Tax and Trade Bureau, 550 Main St, Ste 8002,
Cincinnati, OH 45202-5215.

a.

2. Applicants are required to furnish, in the manner and detail prescribed in
27 CFR Part 19, the following information:

c.

a.

b.

Statement of business organization and of the persons interested in
the business, supported by the corporate documents, articles of
partnership, and/or statement of interest in the business, as required
by 27 CFR Part 19. (Where any statement or document required by
this paragraph is on file with the Director, NRC, such statement
or document may, by incorporation by reference thereto by the
applicant, be made part of the application for an operating permit.)
List of the trade names to be used in connection with the operations
specified in the application, showing the operation or operations in
which each trade name will be used. If State or local law requires
registration of trade names, evidence of such registration must be
furnished. If such registration is not required, a statement to that
effect must be furnished.

b.

Ever been convicted of a felony or misdemeanor under Federal or State
law.
Ever been arrested or charged with any violation of Federal or State
law (convictions or arrests or charges for traffic violations need not
be reported if such violations are not felonies).
Ever applied for, held, or been connected with a permit, issued under
Federal Law, to manufacture, distribute, sell, or use spirits or products
containing spirits, whether or not for beverage use, or held any financial
interests in any business covered by such permit, and, if so, give the
number and classification of such permit, the period of operation thereunder, and state in detail whether such permit was ever suspended,
revoked, annulled, or otherwise terminated. (Where any information
required by this subparagraph is on file with the Director, NRC, such
information may, by incorporation by reference thereto by the applicant,
be made a part of the application for an operating permit.)

4. Applicants, when so instructed by the Director, NRC, are required to furnish
as part of the application for an operating permit such additional information as
may be necessary to the Director, NRC, to determine whether such permit
should be issued.

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
Privacy Act of 1974 (5 U.S.C. §552a(e)(3)):
1. AUTHORITY. Solicitation of this information is made pursuant to
26 U.S.C. §5171(d). Disclosure of this information by the applicant is
mandatory if the applicant wishes to obtain an operating permit.
2. PURPOSE. To identify the applicant, to identify the location where
the plant will be located, and to determine the eligibility of the applicant to obtain an operating permit.
3. ROUTINE USES. The information will be used by TTB to make
the determination set forth in paragraph 2. In addition, the information

TTB F 5110.25 (6/2006)

may be disclosed to other Federal, State, foreign and local law enforcement and regulatory agency personnel to verify information on
the application where such disclosure is not prohibited by law. The
information may further be disclosed to the Justice Department if it
appears that the furnishing of false information may constitute a
violation of Federal law. Finally, the information may be disclosed to
members of the public in order to verify the information on the application where such disclosure is not prohibited by law.
4. EFFECTS OF NOT SUPPLYING INFORMATION REQUESTED.
Failure to supply complete information will delay processing and may
result in the denial of the application.

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 USC 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 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 information unless it displays a current, valid OMB control number.

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TTB F 5110.25 (6/2006)