Form TTB F 5110.25 TTB F 5110.25 Application for Permit Operating Permit Under 26 U.S.C.

OMBOMB
No. 1513-0040
(01/31/2012)
Form Approved:
No. 1513-0040
(12/31/2008)

1. Date

DEPARTMENT OF THE TREASUR<
$LCOHOL AND TOBACCO TAX AND TRADE BUREAU

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 OT+ER (Specify)
bottling) FOR NON-INDUSTRIAL USE

WAREHOUSING OF SPIRITS FOR
INDUST5IAL 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. SIG1ATURE

7. 7ITLE OR STATUS (State whether individual owner, member of firm,
or if officer of corporation, give title)

INSTRUCTIONS
1. ASplication for an oSerating pHrmit undHU 26 U.S .C, 5171( d), must be
submitted on this form, in duplicate, to the Director, National Revenue Center
(NRC), Alcohol and TRbacco Tax and Trade Bureau, 550 Main St, Ste 8002,
Cincinnati, OH 45202-5215.

a.

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

c.

a.

b.

Statement of business organi]ation and of the persons iQterested in
the buViness, suSported byWKHFRUSRUDWH doFXPHQWV, arWLFOHV oI
partnership, and/or statement of interest in the business, as required
by 27 CFR Part 19 . (Where any statement or document required by
this pDragraph iV on file ZLWK Whe Director,NRC, suchstaWHPHQW
or documenW mayE\ incorporatioQ b\ referencethereto by the
applicant, be made pa rt of the application for an operDWLQJ permit.)
List of the trade names to be used in connection with the operations
specified in the aSSOLFDWLRQ, showing the operaWLRQ orRperations in
which each trade name w ill be Xsed. If SWate or local lDZ requires
registration of tradH nameV, evLdence of such rHgistration must be
furnished. If sucKregistraWion is not requiredD statement toWhat
effect must be furnished.

b.

Ever been convLcted of a felony or misdemeanor undHU Federal or State
law.
Ever been arreVted or Fharged wLth an\ violation of FedeUal orState
law (convictions or arrests RU charges for traIfic vLolations nHed noW
bereported if such violations are not felonies).
Ever applied for held, or bHen connected ZLth a peUmit, issuedunder
Federal L aw, to mDnufacture, diVtribute, sell, or uVe spirits orpUoducts
containing spirits, whether or not for beverage use, or held anyfinancial
interests in any busineVs covHred by suFh permiW, and , if so, giv e the
number and classification of such permit, the period of oSeration thereunder, and state iQ deWail wKether Vuch permiW wDs evHr suspended,
revoked, annulleG, or otheUwise teUminated. (:hereDny information
required bytKis subparagraphis on fLle wLth the DireFtor, NRC,sXch
information may, by incorporation by referenFe thereto by the appliFant,
be made a part of the application for an operating permit.)

4. ApSlicants, when so instructed by the Director, NRC, are requirHd to furnish
as part of the application for an operating permit such adGitional inIormation as
may be necHssary tR the DirectRr, NRC, Wo detHrmine wKether sucK 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 thiV information is made pXrsuant 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 ORFDWHG, DQG to determine t he eligibLOLW\ of thH applicant to obtain an operating permit.
3. ROUTINE USES. The information will beused byTTB to makH
the determination set forth in paragraph 2. In addition, the information

TTB F 5110.25 (/2009)

may be disclosHG to otheU FeGHUDO, State, forHLJQ and local laZHQ
forcement aQGrHJXODWRU\Dgency personnel toveri fy inIRUPDWLRQ on
the applicatiRQ where such disclRVXUH is not proKLELWHG b\ lDZ.TKH
information mD\ further be discloVHG to thH Justice Depart ment if iW
appears that Whe furnishiQJ of fDOVH inforPDWLRQ may constitXWH a
violation of FHGHUDO law. FinDOO\, the information may be disclosHG to
membersof the public in ordHUtoverify the information on thH application where suFh disclosure is not prohibited by law.
4. EFFECTS OF NOT SUPPLYING INFORMATION REQUESTED.
Failure to suppl\ complete infRrmation will delay prRcessing and may
result in the denial of the application.

PAPERWORK REDUCTION ACT NOTICE
TKis request is in accordance withthe Paperwork Reduction Act 195. The infoUmation collection is uVeG
to determiQe the eligibilityof theDpplicant toHngage inFertain operations, toGetermine lRcation and
extent of operations, and todetermine whether the operationswill beinconformity with Federal laws anG
regulations.7he infoUmation requHVWHG isUequired to obtainorUetain a bHQHILW and iV mDQGDWRU\ 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 WKHReports 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 (/200)