5120 17 Form PDF Details

The 5120 17 form is a document that is used to report the sale or exchange of property between related parties. The form must be completed and filed with the IRS within 45 days of the sale or exchange. There are a number of different items that must be reported on the 5120 17 form, so it is important to understand exactly what needs to be included. This article will provide an overview of the 5120 17 form and how it should be filled out. Additional resources are also provided for those who need more assistance in completing this process.

QuestionAnswer
Form Name5120 17 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names5120 form, report premises, ttb report wine premises, ttb report form treasury template

Form Preview Example

FOR USE 01/01/18 - 12/31/19

 

 

 

 

 

 

OMB No. 1513-0053 (11/30/2020)

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OF THE TREASURY

 

 

 

 

 

 

 

 

 

 

 

 

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)

 

 

 

 

 

 

 

 

 

 

 

 

REPORT OF WINE PREMISES OPERATIONS

 

PERIOD COVERED (Year Only, or Year & Month, or Year & Quarter)

 

OPERATED BY (Name, Address, and Telephone)

 

YEAR ____________ MONTH _______________

 

 

 

 

48$5 7( 5 /<

 

 

January to March

 

July to September

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

April to June

 

October to December

 

 

 

_____________

______________________

___

_____________________

_______________________________________________________________________________________________________________

 

 

 

_____

 

 

 

 

 

_________

_________

VERSION (Select Original or Amended. Select Final also if last report for the business) EIN

REGISTRY NUMBER

 

 

 

 

___________________

 

 

 

 

__________________________________________________________________

 

__

Original

 

__

__

 

Final Report

 

 

 

 

 

Amended

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_

_

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS

 

1.The reporting period for this form must be monthly, except that proprietors who qualify under the exception stated in 27 CFR 24.300(g)(2) may file this form on a TXDUWHUO\RUcalendar year EDVLVXQOHVVrequired to file monthly by the Alcohol and Tobacco Tax and Trade Bureau (TTB). $SURSULHWRUwho files monthly reports but does not expect any reportable operations in a VXEVHTXHQWPRQWKor months may indicate in Part X that no monthly reports will be filed until a UHSRUWDEOHRSHUDWLRQoccurs (§ 24.300(g)(1)).

3.Explain any unusual operations in Part X.

4.The quantities "on hand end" will ordinarily be "book inventory" figures, that is the quantity required to balance each summary. Use the "on hand end" from your report for the previous period as the "on hand beginning" of the current report. On reports for any period when you take a physical inventory, report the difference as losses for bulk wine and shortages for bottled wine, or as gains, as the case may be.

2.

Prepare this form in duplicate and file it by the fifteenth day after the end of the report period

5. If the quantity of wine previously reported on TTB F 5120.17temp is affected by adjustments made

 

( PRQWKTXDUWHUor year). Keep the copy on your bonded wine premises for inspection by TTB

 

RIILFHUVSend the original to TTB at this address:'LUHFWRU1DWLRQDO5 HYHQXH& HQWHU$OFRKRODQG

on a tax return, TTB F 5000.24, adjust the current TTB F 5120.17temp in Section A (and Section B, if

Tobacco Tax and Trade Bureau, 550 Main St, Ste 8002, Cincinnati, OH 45202-5215.

bottled wine is involved). Explain the entries in Part X.

 

 

 

 

 

 

 

__________________________________________________________________

 

 

 

 

 

PART I - SUMMARY OF WINES IN BOND (GALLONS)

 

 

 

 

 

 

 

 

ALCOHOL CONTENT BY VOLUME

 

ARTIFICIALLY

 

 

 

 

 

 

ITEM

NOT OVER 16

 

OVER 16 TO 21 PERCENT

OVER 21 TO 24 PERCENT

 

CARBONATED

SPARKLING WINE

HARD CIDER1/

 

 

 

 

 

WINE

 

 

 

 

PERCENT

 

(Inclusive)

(Inclusive)

 

(e)

(f)

 

 

 

 

(a)

 

(b)

(c)

 

(d)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION A - BULK WINES

 

 

 

 

 

 

 

 

 

 

1.

ON HAND BEGINNING OF PERIOD

 

 

 

 

 

 

 

 

 

2.

PRODUCED BY FERMENTATION2/

 

 

 

 

 

 

BF

 

 

 

 

 

 

 

 

BP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

PRODUCED BY SWEETENING

 

 

 

 

 

 

 

 

 

 

4.

PRODUCED BY ADDITION OF WINE SPIRITS

 

 

 

 

 

 

 

 

 

 

5.

 

PRODUCED BY BLENDING

 

 

 

 

 

 

 

 

 

 

6.

 

PRODUCED BY AMELIORATION

 

 

 

 

 

 

 

 

 

 

7.

 

RECEIVED IN BOND

 

 

 

 

 

 

 

 

 

 

8.

BOTTLED WINE DUMPED TO BULK

 

 

 

 

 

 

 

 

 

 

9.

 

INVENTORY GAINS

 

 

 

 

 

 

 

 

 

 

10.

 

 

 

 

 

 

 

 

 

 

 

11.

 

 

 

 

 

 

 

 

 

 

12.

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

BOTTLED3/

 

 

 

 

 

 

BF

 

 

 

 

 

 

 

 

BP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

REMOVED TAXPAID

 

 

 

 

 

 

 

 

 

 

15.

TRANSFERS IN BOND

 

 

 

 

 

 

 

 

 

 

16.

REMOVED FOR DISTILLING MATERIAL

 

 

 

 

 

 

 

 

 

 

17.

REMOVED TO VINEGAR PLANT

 

 

 

 

 

 

 

 

 

 

18.

USED FOR SWEETENING

 

 

 

 

 

 

 

 

 

 

19.

USED FOR ADDITION OF WINE SPIRITS

 

 

 

 

 

 

 

 

 

 

20.

USED FOR BLENDING5/

 

 

 

 

 

 

 

 

 

 

21.

USED FOR AMELIORATION

 

 

 

 

 

 

 

 

 

 

22.

USED FOR EFFERVESCENT WINE

 

 

 

 

 

 

 

 

 

 

23.

USED FOR TESTING

 

 

 

 

 

 

 

 

 

 

24.

 

 

 

 

 

 

 

 

 

 

 

25.

 

 

 

 

 

 

 

 

 

 

 

26.

 

 

 

 

 

 

 

 

 

 

 

27.

 

 

 

 

 

 

 

 

 

 

 

28.

 

 

 

 

 

 

 

 

 

 

 

29.

LOSSES (OTHER THAN INVENTORY)

 

 

 

 

 

 

 

 

 

 

30.

INVENTORY LOSSES

 

 

 

 

 

 

 

 

 

 

31.

ON HAND END OF PERIOD

 

 

 

 

 

 

 

 

 

32.

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION B - BOTTLED WINES

 

 

 

 

 

 

 

 

 

1.

ON HAND BEGINNING OF PERIOD

 

 

 

 

 

 

 

 

 

 

2.

 

BOTTLED3/

 

 

 

 

 

 

BF

 

 

 

 

 

 

 

 

 

 

 

 

BP

 

 

 

3.

 

RECEIVED IN BOND

 

 

 

 

 

 

 

 

 

 

4.

TAXPAID WINE RETURNED TO BOND

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

 

 

7.

 

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

 

REMOVED TAXPAID

 

 

 

 

 

 

 

 

 

 

9.

 

TRANSFERRED IN BOND

 

 

 

 

 

 

 

 

 

 

10.

DUMPED TO BULK

 

 

 

 

 

 

 

 

 

 

11.

USED FOR TASTING

 

 

 

 

 

 

 

 

 

 

12.

REMOVED FOR EXPORT

 

 

 

 

 

 

 

 

 

 

13.

REMOVED FOR FAMILY USE

 

 

 

 

 

 

 

 

 

 

14.

USED FOR TESTING

 

 

 

 

 

 

 

 

 

 

15.

 

 

 

 

 

 

 

 

 

 

 

16.

 

 

 

 

 

 

 

 

 

 

 

17.

 

 

 

 

 

 

 

 

 

 

 

18.

BREAKAGE

 

 

 

 

 

 

 

 

 

 

19.

INVENTORY SHORTAGE4/

 

 

 

 

 

 

 

 

 

 

20.

ON HAND END OF PERIOD

 

 

 

 

 

 

 

 

 

21.

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1/ Hard cider: (a) Contains no more than 0.64 gram of carbon dioxide per 100 milliliters of wine; (b) Is derived primarily from apples or pears, or from apple juice concentrate or pear juice concentrate and water, as described in 27 CFR 24.332(a); (c) Contains no fruit product or fruit flavoring other than apple or pear, as described in 27 CFR 24.332(b) and (c); and (d) Contains at least one-half of 1 percent and less than 8.5 percent alcohol by volume.

2/ Enter in col. (e) on line marked "BF" the quantity of sparNling wine produced by fermentation in bottles, and on line marked "BP" the quantity of sparNling wine produced by bulk process.

3/ Section A line 13 and Section B line 2 should shoZ the same quantities. Enter in col.(e) on line marked "BF" the quantity of finished bottle fermented sparkling wine bottled, and on line marNed "BP" the quantity of finished bXlk process wine bottled.

4/ Fully explain in either Part X, or on a separate signed statement submitted with this report. Failure to satisfactorily explain shortages of bottled wine may result in the assessment of taxes applicable to those shortages. 5/ Only report blending if wines of different tax classes are blended together.

1 of 2

TTB F 5120.17temp (01/2018)

FOR USE 01/01/18 - 12/31/19

PART II - (RESERVED)

 

 

 

 

 

 

 

 

 

PART III - SUMMARY OF DISTILLED SPIRITS (Proof Gallons)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WINE SPIRITS

 

 

 

 

 

 

 

 

 

DISTILLATES CONTAINING

SPIRITS FOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USE IN NON

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

 

 

 

 

 

 

 

 

 

 

 

FOR ADDITION TO WINE6/

 

 

 

 

FOR PREPARATION

 

 

ALDEHYDES6/

BEVERAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OF DOSAGES OR

 

 

 

 

 

 

 

WINES

 

 

 

 

 

 

 

 

 

 

 

GRAPE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ESSENCES

 

 

 

 

 

 

 

(h)

 

 

 

 

 

 

 

 

 

 

 

 

(a)

 

(b)

 

 

(c)

 

 

 

(d)

 

 

 

(e)

 

(f)

 

(g)

1.

ON HAND BEGINNING OF PERIOD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

INVENTORY GAIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

USED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

TRANS. TO COL. (e)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

LOSSES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. ON HAND END OF PERIOD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

 

 

 

 

 

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART IV - SUMMARY OF MATERIALS RECEIVED AND USED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GRAPE MATERIAL

 

 

 

 

 

 

KINDS OF MATERIALS OTHER THAN GRAPE6/

 

SUGAR

 

 

 

 

 

 

 

 

 

GRAPES

 

 

 

 

 

 

 

 

 

 

 

 

 

(Pounds or Gallons)

 

 

 

 

 

 

DRY

LIQUID

 

ITEM

 

 

UNCRUSHED

FIELD CRUSHED

JUICE

 

CONCENTRATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Pounds)

(Gallons)

 

 

 

 

 

 

 

(Pounds)

 

 

(Gallons)

(Gallons)

 

(Gallons)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(e)

 

 

(f)

 

 

(g)

 

(h)

(i)

 

 

 

 

 

 

 

(a)

 

 

 

(b)

 

(c)

 

 

(d)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

ON HAND BEGINNING OF PERIOD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

JUICE OR CONCENTRATE PRODUCED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

USED IN WINE PRODUCTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. USED IN JUICE OR CONCENTRATE PRODUCTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

USED IN ALLIED PRODUCTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

REMOVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

ON HAND END OF PERIOD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

 

 

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART V - (RESERVED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART VI - SUMMARY OF DISTILLING MATERIAL AND VINEGAR STOCK (Gallons)6/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISTILLING MATERIAL7/

 

 

 

 

 

 

 

 

 

VINEGAR STOCK

 

 

 

ITEM

 

 

 

 

 

 

 

 

 

(a)

 

 

 

 

 

(b)

 

 

 

 

 

 

 

(c)

 

 

 

 

 

 

(d)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

ON HAND BEGINNING OF PERIOD (Storage Tanks)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

PRODUCED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. RECEIVED FROM OTHER BONDED WINE PREMISES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. REMOVED TO DISTILLED SPIRITS PLANTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. REMOVED TO OTHER BONDED WINE PREMISES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. REMOVED TO VINEGAR PLANTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. ON HAND END OF PERIOD (Storage Tanks)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

 

 

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART VII - IN FERMENTERS END OF PERIOD (Gallons) 6/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

 

 

 

 

 

 

 

 

(a)

 

(b)

 

 

(c)

 

 

 

(d)

 

 

(e)

 

 

 

 

 

 

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

IN FERMENTERS (ESTIMATED QUANTITY OF LIQUID)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART VIII - SUMMARY OF NONBEVERAGE WINES (Gallons)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOT OVER 16 PERCENT ALCOHOL

OVER 16 TO 21 PERCENT ALCOHOL

 

 

 

TOTAL

 

 

 

ITEM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Inclusive)

 

 

 

 

 

 

(c)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)

 

 

 

 

 

 

 

 

 

 

 

(b)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

PRODUCED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

WITHDRAWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART IX - SPECIAL NATURAL WINES AND 27 CFR 24.218 WINES (Gallons)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER SPECIAL NATURAL WINES

 

 

 

 

 

 

 

TOTAL

 

 

 

 

 

 

27 CFR

 

ITEMS

 

VERMOUTH

 

 

NOT OVER 16

 

 

OVER 16 TO 21

 

ARTIFICIALLY

 

SPARKLING

 

 

 

 

 

 

 

 

 

 

 

PERCENT ALCOHOL

PERCENT ALCOHOL

 

CARBONATED

 

 

 

(cols. a, b, c, d and e)

 

 

24.218 WINES

 

 

 

(a)

 

 

 

 

 

(e)

 

 

(f)

 

 

 

 

 

 

(g)

 

 

 

 

 

 

 

 

 

 

(b)

 

 

 

(c)

 

 

 

 

 

(d)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

PRODUCED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

TAXABLE REMOVALS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

ON HAND END OF PERIOD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART X - REMARKS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Under penalties of perjuryI decOare that I haYe examined this report, incOuding the documents submitted in supporW thereof and to the best of m\ knoZledge and belief, it is true correct, and complete.

 

PROPRIETOR

BY (Signature)

(Printed Name and Title)

DATE

 

 

 

 

 

6/ State kind - apple, blackberry, etc.

 

 

 

7/ Distilling material includes lees, filter wash, and other residues used fRr production of wine spirits. See 27 CFR 24.306.

 

 

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 by payment on untaxpaid commodities. The information required is mandatory by statute (26 U.S.C. 5367).

The estimated average burden associated with this collection of information is 1 hour and 6 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 Office, Regulations and Rulings Division, Alcohol and Tobacco Tax and Trade Bureau, 1310 G Street, NW, Box 12, 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.

2 of 2

TTB F 5120.17temp (01/2018)

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ttb report operations completion process outlined (stage 1)

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