TTB F 5130.Pilot-A Pilot Brewer Excise Tax Return for First Semi-Monthly Pe

OMB No. 1513-XXXX
DEPARTMENT OF THE TREASURY

Alcohol and Tobacco Tax and Trade Bureau

PILOT BREWER EXCISE TAX RETURN FOR FIRST SEMI-MONTHLY PERIOD(S) (Semi-Monthly Filers Only)
(TTB F 5130.Pilot-A)

TAXPAYER IDENTIFICATION
1. Serial Number

TR3a. Reporting Year

NOTE: Please make checks or money orders payable to the ALCOHOL AND TOBACCO TAX AND TRADE BUREAU. Show employer

identification number (EIN), Registry Number, and tax period on all checks or money orders. See paper check conversion notice below.*

2a. Amount Paid

2b. Form of Payment

2c. Other

3b. Period Covers

3c. Excise Tax Period (Beginning - Ending Date)

3d. Submission Version

Semi-Monthly
4. Brewer's Notice Number

BR -

5. Employer Identification Number (EIN)

6a. Brewery Contact Name (Authority on file with TTB)

7a. Brewery Name

6b. Brewery Contact Phone Number

7b. Brewery Premises Address (Number, Street & Secondary Address)

6c. Brewery Contact Email Address

7c. Brewery Premises Address Continued (City, County, State & Zip Code)

EXCISE TAX CALCULATION

(Semi-monthly filers: report taxable removals only for the return period specified in line 3c)
8. Beer produced and removed @ $ 3.50 per Barrel

I (or another brewery in my controlled group)
produced this beer and I am eligible for this rate.

9. Beer produced and removed @ $16.00 per Barrel

I (or another brewery in my controlled group)
produced this beer and I am eligible for this rate.

No. of Barrels

Tax Due

Applicable Rate

Tax Due

(a)

(b)

10. Beer Removed @ $18.00 per Barrel
11. Total Taxable Beer Removed and Total Excise Tax Liability (lines 8 + 9 + 10)
12. Total Increasing Adjustments (equals line 23 of SCHEDULE A)
13. Gross Amount Due (lines 11 + 12)
14. Total Decreasing Adjustments (equals line 27 of SCHEDULE A)
15. Amount Due With This Return (line 13 minus line 14)

SCHEDULE A

INCREASING AND DECREASING ADJUSTMENTS
Increasing Adjustments
Supporting Information

(Tax Return Serial # When Shortage First
Type of Increasing Adjustment
(a)

identified, Export Serial #, Prepayment

Unit

Serial # or Alternate Method #)

(c)

(b)

16.

barrels

17.

barrels

18.

barrels

19.

See Attached

(d)

(e)

Enter the total calculated tax from your continuation sheet of increasing adjustments.

20. Total Increasing Tax Due
21. Interest
22. Penalties
23. Total Increasing Adjustments (lines 20 + 21 + 22)

TTB F 5130.Pilot-A (10/2023)

Quantity

Page 1 of 4

(f)

Decreasing Adjustments
Supporting Information

Balance Left on

Serial # w/Return Serial # where paid,

(Not Taken for

Adjustment This

(d)

(e)

Claim

(e.g., Claim #, Prepayment Serial #s, Export
Type of Decreasing Adjustment
(a)

Alternate Method #)

Approved Claim Amount
(c)

(b)

Adjustment)

Amount of
Period

24.
25.
26.

See Attached

Enter the total calculated tax from your continuation sheet of decreasing adjustments.

27. Total Decreasing Adjustments

Signature Under Penalties of Perjury

Under penalties of perjury, I declare that I have examined this Pilot Brewer Excise Tax Return for First Semi-Monthly Period(s) (Semi-Monthly Filers Only)
(including schedule A) and to the best of my knowledge and belief, it is true, correct, and complete including all transactions and tax liabilities
required by law or regulations to be reported.
30. Signature

28. Printed Name

31. Date

29. Title

Notice to Taxpayers Making Payment by Check: If you send us a check, it will be converted into an electronic funds transfer (EFT). This means we will copy
your check and use the account information on it to electronically debit your account for the amount of the check. The debit from your account will usually
occur within 24 hours, and will be shown on your regular account statement. You will not receive your original check back. We will destroy your original
check, but will keep the copy of it. If the EFT cannot be processed for technical reasons, you authorize us to process the copy in place of your original check. If
the EFT cannot be processed because of insufficient funds, we may try to make the transfer up to 2 times.

TTB F 5130.Pilot-A (10/2023)

Page 2 of 4

1
2

Brewery Name

Period Covers

EIN

Brewery Notice Number

BR BR -

SCHEDULE A - CONTINUATION SHEET

INCREASING ADJUSTMENTS TO EXCISE TAX LIABILITY

Type of Increasing Adjustment
(a)

Supporting Information
(Tax Return Serial # When Shortage First
identified, Export Serial # or Alternate Method #)
(b)

Unit
(c)

A.

barrels

B.

barrels

C.

barrels

D.

barrels

E.

barrels

F.

barrels

G.

barrels

H.

barrels

I.

barrels

J.

barrels

K.

barrels

L.

barrels

M.

barrels

N.

barrels

O.

barrels

P.

barrels

Q.

barrels

R.

barrels

S.

barrels

T.

barrels

U.

barrels

V.

barrels

W.

barrels

X.

barrels

Y.

barrels

Z.

barrels

AA.

barrels

AB.

barrels

AC.

barrels

AD.

barrels

AE.

barrels

AF.

barrels

AG.

barrels

AH.

barrels

AI.

barrels

AJ.

barrels

AK.

barrels

AL.

barrels

AM.

barrels

AN.

barrels

AO.

barrels

AP.

barrels

Total Increasing Tax Due

Quantity
(d)

Applicable
Rate
(e)

Tax Due
(f)

1
2

Brewery Name

Period Covers

EIN

Brewery Notice Number

BR BR -

SCHEDULE A - CONTINUATION SHEET

DECREASING ADJUSTMENTS TO EXCISE TAX LIABILITY
Claims for Credit

Type of Decreasing Adjustment
(a)

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
U.
V.
W.
X.
Y.
Z.
AA.
AB.
AC.
AD.
AE.
AF.
AG.
AH.
AI.
AJ.
AK.
AL.
AM.
AN.
AO.

Total Decreasing Tax Adjustments

Supporting Information
(e.g., Claim #, Export Serial # w/Return Serial #
where paid, Alternate Method # or Event Date)
(b)

Approved Claim
Amount
(c )

Balance Left on
Claim
(Not Taken for
Adjustment)
(d)

Amount of Adjustment This Period
(e )