Form TTB F 5100.4 TTB F 5100.4 Certificate of Taxpaid Alcohol

OMB No. 1513-0131 (09/30/2012)
1. CERTIFICATION
NUMBER

DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
CERTIFICATE OF TAXPAID ALCOHOL
2. TO: DIRECTOR OF CUSTOMS AND BORDER PROTECTION
PORT OF
SERIAL
NO. OF
PACKAGE
(a)

TAX PAID AT DISTILLED SPIRITS PLANT
NO.
(b)

OPERATED BY
(c)

PROOF
GALLONS
(d)

PROOF

AMOUNT
OF TAX

DATE
WITHDRAWN

(e)

(f)

(g)

3. I certify that no other certificate covering the above-described alcohol has been issued.
This certificate is issued at the request of
to be used at the port of

on account of

drawback on certain flavoring extracts, and/or medicinal or toilet preparations claimed to have been manufactured by
with the use of the above-described alcohol.
4. DATE

5. SIGNATURE OF APPROPRIATE TTB OFFICIAL

PAPERWORK REDUCTION ACT NOTICE
This information collection request is in accordance with the Paperwork Reduction Act of 1995. The purpose of this information collection is for the
protection of Federal excise taxes. The information will be used to determine compliance with requirements governing drawback of tax on the
exportation of nonbeverage commodities. The information required is voluntary.
The estimated average burden associated with this collection of information is 30 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, Suite 200, Washington, D.C. 20005.
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.

TTB F 5100.4 (09/2012)