TTB F 5100.21 Application, Permit, and Report -- Wine and Beer (Puerto

OMB No. 1513-0123

DEPARTMENT OF THE TREASURY

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

1. SERIAL NO.

APPLICATION, PERMIT, AND REPORT- WINE AND BEER
(Puerto Rico)

Prepare in quintuplicate. - See instructions below.

PART I - APPLICATION
TO THE SECRETARY OF THE TREASURY OF PUERTO RICO
Application is hereby made for a permit to compute the tax on, taxpay, and withdraw for shipment to the United States, the following described wine or beer:
2. DESCRIPTION OF WINE OR BEER
PRODUCED BY
NAME

LOCATION

(a)

(b)

3. TO BE RELEASED FROM PUBLIC
BONDED WAREHOUSE NO.

KIND OF
LIQUORS

FORMULA
NO.

(c)

SERIAL NOS. OF
CONTAINERS

(d)

QUANTITY
WINE

BEER

WINE
GALLONS

TAXABLE GRADE 1

WINE
GALLONS

BBLS

(f)

(g)

(h)

(i)

(e)

3a. OPERATED BY:

3b. LOCATED AT:

4. TO BE RELEASED FOR
Direct shipment

Bottling without rectification

Rectification and bottling

Rectification and packaging

Use in manufacture of articles

Use in manufacture of liqueurs, cordials, etc.

5. CHECK APPLICABLE BOX
5a.

I desire to prepay the computed tax before withdrawal of the liquors.

5b.

I have on file with the District Director (Investigations), Puerto Rico Operations, Alcohol and Tobacco Tax and Trade Bureau a good and sufficient bond
on
TTB Form 5120.32
TTB Form 5130.16 and desire to withdraw the liquors on computation, but before payment, of the tax.

5c.

I desire to withdraw liquors on computation, but before payment, of the tax. I am not required to hold a bond for the withdrawal because I was liable for not
more than $50,000 in taxes in the preceding calendar year, I reasonably expect to be liable for not more than $50,000 during the current calendar year, and
this form does not cover any shipment of wine for industrial use.
6. DATE
7. NAME OF APPLICANT
7a. BY (Signature and capacity)

PART II - PERMIT TO COMPUTE
TO THE COMMONWEALTH INTERNAL REVENUE AGENT

8. PERMIT IS HEREBY GRANTED TO - THE ABOVE NAMED APPLICANT TO COMPUTE THE TAX ON THE LIQUORS DESCRIBED IN PART I,
AND TO:
Prepay the computed tax.
Defer payment of the computed tax.
9. DATE

10. SECRETARY

10a. BY (Signature and official title)

PART III - COMPUTATION OF TAX AND STATEMENT OF TAX PAYMENT

11.

WINE TAX
WINE GALLONS
(a)

TAXABLE
GRADE 1
(b)

12.

BEER TAX

AMOUNT
OF TAX
(d)

RATE OF
TAX
(c)

BARRELS

RATE OF TAX

(a)

(b)

$

TO (Check one)2

District Director (Investigations), Puerto Rico Operations

(c)
$

$

Total Wine Tax

AMOUNT OF TAX

$

Total Beer Tax

Commonwealth Internal Revenue Agent
13. TOTAL AMOUNT OF TAX
$

Under the penalties of perjury, I declare that I have examined the above computation of tax and, to the best of my
knowledge and belief, this statement of tax liability is true, correct, and accurate.
14. CHECK APPLICABLE BOX
14a

TTB Form 5000.25, with remittance in full for the total amount of the above tax, is transmitted herewith.

14b.

I agree to pay, as required by law and regulations, the total amount of tax shown in item 13 and I declare, under the penalties of perjury, that I am not in default in any payment of tax chargeable
against my bond,
TTB Form 5120.32,
TTB Form 5130.16, and that such bond is in the maximum penal sum or is sufficient to cover that amount in addition to all other amounts chargeable
against such bond.

14c.

I agree to pay, as required by law and regulations, the total amount of tax shown in item 13 and I declare, under penalties of perjury, that I was liable for not more than $50,000 in taxes in the
preceding calendar year, I reasonably expect to be liable for not more than $50,000 during the current calendar year, and am not using this form for any shipment of wine for industrial use.

15. DATE

16. NAME OF APPLICANT

16a. BY (Signature and capacity)

1

If champagne or other sparkling wine is being withdrawn, insert "Champ.," or, if artificially carbonated wines are being withdrawn, Insert "Art. Carb." For other wines
see 27 CFR 26.93
2
If the computed tax is to be prepaid, check "District Director (Investigations), Puerto Rico Operations;" if the computed tax is to be deferred, check "Revenue Agent."

TTB FORM 5100.21 (11/2016)

PREVIOUS EDITIONS ARE OBSOLETE

PART IV - REPORT OF PREPAID TAXES
TO COMMONWEALTH INTERNAL REVENUE AGENT
17.
18. DATE

TTB Form 5000.25, with remittance in full for the amount of tax shown in Part III, has been received.
19. DISTRICT DIRECTOR (INVESTIGATIONS), PUERTO RICO OPERATIONS

19a. BY (Signature and official title)

PART V - REPORT OF RELEASE

TO THE SECRETARY OF THE TREASURY OF PUERTO RICO
20.
20a.
20b.
20c.

21. DATE

TTB Form 5000.25, with remittance in full, has been received by the District Director (Investigations), Puerto Rico Operations.
The applicant has on file a good and sufficient bond to cover the taxes described in Part III; therefore, the wine or beer described in Part I has been released
for the purpose indicated.
The applicant is not required to hold a bond because the applicant has declared that the applicant was liable for not more than $50,000 in taxes in the
preceding calendar year, reasonably expects to be liable for not more than $50,000 during the current calendar year, and is not using this form for any
shipment of wine for industrial use.
22. REVENUE AGENT

INSTRUCTIONS
1. GENERAL. The applicant must prepare this form in quintuplicate.

Forms must be serially numbered beginning with “1” each calendar year, and
running consecutively there after to the e nd of th e year. The serial numbe r
must be prefixed by the last two digits of the calendar year, e.g., “10-1.”

2. PART I. After executing Part I, the applicant must forward all copies of this
form to the Secretary of the Treasury of Puerto Rico.

3. PART II. A fter executing the permit in Part II, the Secretary must retain
one copy of this form for his/her files and return the original and remaining
copies to the applicant.
4. PART III. (a) Prepayment. If the tax is t o be prepaid, the applicant
must so indicate in P art III. On executing Part III, the applicant must
prepare TTB Form 5000.25, in acc ordance with the instructions on the
form, and send all copies of this form and the original and two copies of
TTB Form 5000.25 and remittance in the f ull amount of t he t ax, to the
District Director (Investigations), Puerto Rico Operations, TTB. Ste 310
Torre Chardon, 350 Carlos Chardon Ave, San Juan, PR 00918.

(b) De ferred Pa yment. If th e ta x i s to be deferred, the ap plicant must ,
after executing his/her agreement to pay in P art III, deliver all c opies to
the revenue agent.
5. PART IV. This part must be dated and signed by the District Director
(Investigations), Puerto Rico Operations, if t he tax is prepaid. H e/She
must then forward one copy of TTB Form 5000.25 to the Secretary,
forward one copy of T TB Form 5000.25 and two copies of TTB Form
5100.21 to th e r evenue a gent, a nd ret ain t he or iginal of TTB Form
5100.21 and TTB Form 5000.25.
6. PART V. This part m ust b e executed by the r evenue a gent af ter
determining that the applicant has proper bond coverage, or in the case
of prepayment, on receipt of TTB F 5100.21 f rom the District Director
(Investigations), Puerto Rico Operations reporting his/her receipt of
TTB Form 50 00.25 with remittance in full. The revenue agent must
then forward one copy of this form to the Insular Liquor Bureau and one
copy to the District Revenue Agent (Commonwealth of Puerto Rico),
deliver one copy to the applicant, and retain one copy each of this form
and TTB Form 5000.25 for his/her files.

PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. The information collection is used to determine the eligibility of the person to compute the tax
on, taxpay, and withdraw wine or beer. The information is mandatory by statute (26 U.S.C. 7652).
The estimated average burden associated with this collection of information is 1 hour 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, 1310 G Street, N.W., Box 12, Washington, DC 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 FORM 5100.21 (11/2016)