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                                                                                                                                          OMB No. 1513-0016 (03/31/2013)
                                    DEPARTMENT OF THE TREASURY                                                               1.  SERIAL NUMBER (The exporter will number
                              ALCOHOL AND TOBACCO TAX AND TRADE BUREAU                                                               each  form beginning with "1" each January 1.)
                              DRAWBACK ON WINES EXPORTED
                                                  (See instructions below)
                                                  PART I - NOTICE                                                                             (FOR TTB USE ONLY)
2.  TO                                           Director, National Revenue Center / Alcohol and Tobacco Tax and Trade Bureau
                                     550 Main St., Ste 8002
                                     CincinnatI, OH  45202-5215
 The undersigned gives notice,                                                ,of the shipmentCLAIMof winesNUMBERmanufactured  bottled  or packaged in the United States 
 on which drawback of the Internal Revenue tax paid or determined is claimed.
3.  EXPORTER - NAME AND,ADDRESS4. Permit/Registry(Number,DATEStreet,RECEIVEDNumberCity, State  Zip Code
    
                                                                                                                             TTB F 5620.4
5. EMPLOYER IDENTIFICATION NUMBER                                                                                            FILED WITH CLAIM NO.2
                           SHIPMENT FOR               TRANSFER TO         (Number)                            (Location)     AMOUNT CLAIMED
6.  PURPOSE                EXPORT TO ARMED            FOREIGN TRADE                                                          $
         OF                FORCES OF THE U.S.         ZONE                                                                   AMOUNT REJECTED
 SHIPMENT              EXPORTATION TO (Name of foreign port and country)                                                     $
   (Make
   applicable                                                                                                                AMOUNT APPROVED
   entries)            USE AS SUPPLIES ON             A VESSEL3           AIRCRAFT3
                                                                                                                             CLAIMS CLERK
                            DIRECTOR OF CUSTOMS AT PORT OF
7.  CONSIGNED
      TO OR IN                                                                                                               8.  NAME OF DOMESTIC CARRIER
     CARE OF           TRANSPORTATION (Name) (Name)                       (Location)                                             
       (Make           OFFICER
    applicable         CUSTOMS OFFICER IN  (Number)                       (Location)                                         9.  NAME OF EXPORT CARRIER
      entries)         CHARGE OF FOREIGN
                       TRADE  ZONE
10.  DESCRIPTION OF WINE SHIPPED
   KIND     NUMBER                  CASES                                                                         ALC.       TOTAL                DRAWBACK
    OF                 OF                         BOTTLES       SERIAL NUMBERS OF                             CONTENT        WINE                 RATE PER WINE
   WINE      PACKAGES                                         CONTAINERS  OR CASES4                                          GALLONS              GALLON
                              NUMBER in case          size
    (a)                (b)          (c)           (d) (e)                 (f)                                     (g)        (h)                             (i)

                                                                          PART II - CLAIM
The wines describedI                                      in Part   have been removed11. forAMOUNTthe purposeCLAIMEDstated, and are not to be brought back or relanded within
the limits of the United States.  The kind, quantity, and description of the wines stated in Part             Ii s correct, and I am             $
justly entitled to drawback of the tax in the amount12                                                                                        .  IclaimedREQUESTherein. DRAWBACKInternal Revenue tax equal to such amount has been 
paid or determined as provided by law and regulations.  No other claim for allowance of drawback has been made under 26                          ALLOWED TO BE PAID
U.S.C. 5062(b), or Section 309 of the Tariff Act of 1930, as amended, on these wines or any part thereof.  Under penalties of        BY
perjury,l                  I dec areI                 that I have examined Part   hereof, and this claim, and to the best of my knowledge and belief the
statements hereinI                                    and in Part  , are true, correct,CHECKandCREDITcomplete.
13.  DATE                4.  EXPORTER                                                                         . SIGNATURE                          14b. TITLE

1Insert, as applicable, plant number of distilled spirits plant, registry number of bonded                    (c) vessel of the United States engaged in trade between Atlantic(c) vessel of the United States engaged in trade between Atlantic
wine cellar or taxpaid wine bottlingandandhouse,PacificPacificor numberportsportsofofofthethethewholesaleUnitedUnitedStates;States;liquor(d)(seldealersvesselemployedemployedin                                                                                                in
permit issued under the Federal Alcoholcountrycountry(1) theAdministrationfisheries:ofor (2)registry,the wd) veshaling business. Act.andSh                                                                                                      ports of call, or if a whaling vessel, location
2Complete only for consolidated claims;ofof vessel,operations.locationshow serialofIfoperations. numberaircraft,of lastshowIfclaimaircraft,alsotabulated.nameshowof airlinealso nameandofcountry of
3State a whether(a) vessel or aircraft operatedregistryairlineby theandofUnitedaircraft.country4                                                             States;of registry(b) vesselof aircraft.or aircraftShow filing date when 
engaged in foreign trade, or in tradeuse4                                                                     ShowbetweenoffillingsuchthedatedateUnitedhaswhenStatesbeenuseauthorizedandof suchany ofdateinitslieuhas beenof serialauthorizednumbersin                                 o
possessions, or between Hawaii or Alaska and any other part of the United States;                             lieu of serial numbers on cases.
TTBTB FF5120.245120.24(0(8/2006/20))
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PART III - CUSTOMS OFFICER'S CERTIFICATION OF LADING OR DEPOSIT
I hereby certify that the wines described in Part I were found as described, except as noted in Item 19, and that the wines were--
15. LADEN FOR VESSEL (Name) AIRCRAFT (Name, symbols, number)

USE AS RAILROAD CAR (Number) TRUCK (State license)
EXPORT SUPPLIES
ON BOARD
16 . RECEIVEDNUMBERIN 17 SHIPPED. 18(Frontier Port)TO . SERIAL NUMBER OF SEALS USED
FOREIGN
TRADE ZONE
19. INSPECTIONI DISCLOSEDNO DISCREPANCIES
NON EVIDENCE OF DISCREPANCY OR SHORT SHIPMENT
TAMPERINGT AS FOLLOWS:
20. DATE 12 . PORT 22. SIGNATURE AND TITLE OF CUSTOMS OFFICER

PART IV - CUSTOMS OFFICER’S PORT REPORT OF THROUGH SHIPMENT AT FRONTIER PORT
23. FRONTIER PORT 24. DATE RECEIVED 25. INSPECTION DISCLOSED : NO EVIDENCE OF TAMPERING
SEALS INTACT
SEALS BROKEN
2 .6 NATURE AND EXTENT OF DISCREPANCIES, TRANSSHIPMENT, RESEALING, ETC.

2 .7 The exporting conveyance noted in Item 15, bearing the wines described in Item 10, FOREIGN PORT
with exceptions as noted in items 2019and 27,andcleared from26,this port for the port of
82 DATE. 29 . SIGNATURE AND TITLE OF CUSTOMS OFFICER

PART V - CERTIFICATE OF CLEARANCE OR USE
30. THE EXPORTING CONVEYANCE BEARING THE WINES DESCRIBED IN ITEM 10, WITH EXCEPTIONS AS NOTED ABOVE --
CLEARED FROM THE PORT OF ON (Date) BOUND FOR (Foreign port)

3 .1 THE WINE HAS BEEN USED AS SUPPLIES ON THE 32. DATE 33. SIGNATURE OF PORT DIRECTOR OF
FISHING VESSEL OR AIRCRAFT IDENTIFIED ABOVE, CUSTOMS
AND THE EVIDENCE OF SUCH USE HAS BEEN
RECEIVED .
PART VI - CERTIFICATE RECEIPT BY ARMED FORCES OFFICER
The wine described in Part I, with exceptions as noted in item 35, were received for export to the Armed Forces of the United States. The wines will
not be shipped for consumption or used in any place subject to the application of the Internal Revenue laws of the United States.
34. DATE 35. DISCREPANCIES

3 .6 SIGNATURE 37. RANK 38. TITLE

INSTRUCTIONS
1. GENERAL. Under 27 CFR 28.212 and 28.214 persons qualified as proprietors of1. GENERAL. Under 27 CFR 28.212 and 28.214 persons qualified as proprietors of distilled and forward them to the Port Director of Customs. The Port Director, on receipt of the
distilled spirits plants, bonded wine cellars, or taxpaid wine bottling houses, or holdingspirits plants, bonded wine cellars, or taxpaid wine bottling houses, or holding wholesale liquor required ”Certificates of Use” (for aircraft) or Customs Form 5125 (for fishing vessels), must
wholesale liquor dealer permits issued under the Federal Alcohol Adminstration Act, aredealer permits issued under the Federal Alcohol Administration Act, are authorized to file claims execute Part V, forward the original to the Director, NRC, Alcohol and Tobacco Tax and Trade
authorizedon Formto file claims5120.24on Form 5120.24 forforallowanceallowanceof drawback of Internal Revenueof drawbackBureau at the addressof Internalshown in item 2, and retainRevenuethe copy for his/hertaxes.files. (c) Lading at Interior
taxes. Port For Exportation Through Frontier Port. On completion of lading, the Customs officer
2. NUMBER OF COPIES. Prepare this form in quadruplicate, except prepare a fifth copy,2. NUMBER OF COPIES. Prepare this form in quadruplicate, except prepare a fifth copy, will affix the seals, then execute Part III on both copies and forward them to the Port
marked “Consignee’s Copy,” where the wine is for use on an aircraft.marked “Consignee’s Copy,” where the wine is for use on an aircraft. Director of Customs at the interior port of lading for forwarding to the Customs officer at the
frontier port. That officer, when satisfied that the shipment has been exported, must execute
3. INSTRUCTIONS TO EXPORTER. Complete Part I and execute Part II. If you are a3. INSTRUCTIONS TO EXPORTER. Complete Part I and execute Part II. A proprietor may Part IV on both copies and return them to the Port Director of Customs at the interior port.
proprietor of a bonded wine cellar, you may elect (item 12) to have a drawback allowanceelect (in item 12) to recoup an approved drawback allowance by check or credit. A check or ACH The Port Director will then execute Part V, forward the original to the Director, NRC,
paidelectroniceither by check or by creditpayment(TTBF 2639) ,whichwillcan be claimedbeonissueda subsequent if theAlcohol"Check"and Tobacco Tax andboxTrade Bureauisatmarked.the address shown inAnitem 2, andapprovedretain the credit can be taken
tax return on Form 5000.24; all other claimants should check the box designated “Check”. Onas a decreasing adjustment on one or more Excise Tax Returns (Form 5000.24). On shipments copy for his/her files. (d) Receipt in Foreign Trade Zones. On receipt of the wine, the Customs
shipmentsof theof the wine,wine,forward theforwardoriginal and one copytheof this formoriginalto the official designatedandin oneofficer mustcopyexecute PartofIII on boththiscopies, forwardformthe originaltotothethe Director,officialNRC,designated
Item 7, forward one copy to the Director, NRC, Alcohol and Tobacco Tax and Trade Bureau in Item 7, forward one copy to the Director, NRC, Alcohol and Tobacco Tax and Trade Bureau Alcohol and Tobacco Tax and Trade Bureau at the address shown in item 2, and retain the
at the address shown in item 2, and retain a copy in your files. If a “Consignee’s Copy” has at the address shown in item 2, and retain a copy in your files. If a “Consignee’s Copy” has copy for his/her files.
been prepared (see instruction 2), forward it to the airline company at the airport.been prepared (see instruction 2), forward it to the airline company at the airport. 5. ACTION BY ARMED FORCES OFFICER. On receipt of the wines, the officer to whom
4. ACTION BY CUSTOMS. (a) Shipment for Direct Exportation, or Use on Vessels Other4. ACTION BY CUSTOMS. (a) Shipment for Direct Exportation, or Use on Vessels Other Than consigned (or other authorized supply officer) must execute Part VI on both copies, forward
Than Fishing Vessels. After inspection of lading, the Customs officer must execute Part IV,Fishing Vessels. After inspection of lading, the Customs officer must execute Part IV, forward the original to the Director, NRC, Alcohol and Tobacco Tax and Trade Bureau at the address
forward the original to the Director, NRC, Alcohol and Tobacco Tax and Trade Bureau at thethe original to the Director, NRC, Alcohol and Tobacco Tax and Trade Bureau at the address shown in item 2, and retain the copy for his/her records.
address shown in item 2, and retain the copy for his/her files. (b) Use on Aircraft and Fishing
Vessels. After inspection of lading, the Customs officer must execute Part III on both copiesshown in item 2, and retain the copy for his/her files. (b) Use on Aircraft and Fishing Vessels. RETENTION PERIOD: The retention period is three years from the record date or the date
After inspection of lading, the Customs officer must execute Part III on both copies of the last entry required to be made on the record, whichever is later. The appropriate
TTB officer may require records to be kept an additional period not to exceed three years.
PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with Paperwork Reduction Act of 1995. This information collection is used to obtain drawback of taxes on wine exported from the United States. The
information is required. . . toPAPERWORKobtainREDUCTIONaACTbenefitNOTICE under 26 U S C 5062.
ThisThe estimatedrequest isaveragein accordanceburdenwithassociatedPaperworkwithReductionthis collectionAct of 1995.of informationThis informationis 1 hourcollectionand 7 minutesis usedpertorespondentobtain drawbackor recordkeeper,of taxes on winedependingexportedon individualfrom the Unitedcircumstances.States. The
information is required to obtain a benefit under 26 U.S.C. 5062.Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to the Report Management Officer, Regulations and
Rulings Division, Alcohol and Tobacco Tax and Trade Bureau, Washington, D.C. 20220.
The estimated average burden associated with this collection of information is 1 hour and 7 minutes per respondent or recordkeeper, depending on individual circumstances. Comments
concerningAn agency maythe,accuracynot conductof thisor sponsor , burden estimateand a personand, suggestionsis not requiredfor reducingto respondthistoburdena collectionshouldofbeinformationaddressed tounlessthe Reportit displaysManagementa current Officer,validRegulationsOMB controlandnumber.Rulings Division,
Alcohol and Tobacco Tax and Trade Bureau, Washington, D.C. 20220.
TTB F 5120.24 (7/2006) 6
(See Item 2 )
An agency may not conduct or sponsor, and aSEALSperson isINTACTnot required to respond to, a collection of information unless it displays a current, valid OMB control number.
TTB F 5120.24 (0 /20) 24. DATE RECEIVED 25. INSPECTION DISCLOSED :
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