OMB NO. 1513-0112 (03/31/2012) 
                                              DEPARTMENT OF THE TREASURY 
                                 ALCOHOL AND TOBACCO TAX AND TRADE BUREAU 
                        SPECIAL TAX REGISTRATION AND RETURN – TOBACCO 
                              (Please Read Instructions Sheet Carefully Before Completing This Form) 
                                              FOR TTB USE ONLY 
      TAX               FAILURE TO FILE       FAILURE TO PAY              INTEREST                          TOTAL 

                                 SECTION I – TAXPAYER IDENTIFYING INFORMATION 
EMPLOYER IDENTIFICATION NUMBER(Required see instructions    )       BUSINESS TELEPHONE NUMBER 
                                                                    (           )      
NAME (Last, First, Middle) or CORPORATE NAME (If Corporate)         DOING BUSINESS AS 
                                                                          
MAILING ADDRESS (Street address or P.O. Box)                        CITY                              STATE    ZIP CODE 
                                                                                                                     
                                 ACTUAL LOCATION (if different than above) 
PHYSICAL PLACE OF BUSINESS ADDRESS (Street Address)                 CITY                              STATE    ZIP CODE 
                                                                                                                     
TAX PERIOD COVERING     (only one tax period per form)  FROM:             (mm/dd/yyyy)  TO: June 30,                (yyyy)
                                             SECTION II TAX COMPUTATION 
             TAX CLASS DESCRIPTION 
        (for items marked * see instructions)           MONTHLY    ANNUAL LOCATIONS                   TAX DUE       CODE 
                        (a)                                 (b)     (c)    (d)                             (e)      (f) 
Manufacturer of tobacco products $83.33                         1/3$1,000                                           91 
Manufacturer of tobacco products - REDUCED*             $41.66 2/3  $500                                            95* 
Manufacturer of cigarette papers and tubes              $83.33 1/3 $1,000                                           92 
Manufacturer of cigarette papers and tubes – REDUCED*   $41.66 2/3  $500                                            96* 
Proprietor of export warehouse                          $83.33 1/3 $1,000                                           93 
Proprietor of export warehouse – REDUCED*               $41.66 2/3  $500                                            97* 

MAKE CHECK OR MONEY ORDER PAYABLE TO "ALCOHOL AND TOBACCO TAX AND TRADE                              TOTAL TAX DUE  
BUREAU", WRITE YOUR EMPLOYER IDENTIFICATION NUMBER ON THE CHECK AND SEND IT 
                                                                                                     $      
WITH THE RETURN  TO TTB SOT TAX, 550 MAIN ST, STE 8002, CINCINNATI, OH 45202-5215.                    0.00

Under penalties of perjury, I declare that the statements in this return/registration are true and correct to the best of my 
knowledge and belief; that this return/registration applies only to the specified business and location or, where the 
return/registration is for more than one location, it applies only to the businesses at the locations specified on the 
attached list. Note: Violation of Title 26, United States Code 7206, with respect to a declaration under penalties of perjury, 
is punishable upon conviction by a fine of not more than $100,000 ($500,000 in the case of a corporation) or 
imprisonment for not more than 3 years, or both, with the costs of prosecution added thereto. 
Notice to Customers 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 we 
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 completed because of insufficient funds, we may try to make the 
transfer up to 2 times. 
SIGNATURE                        TITLE                                                                DATE 
                                                                                                            
TTB F 5630.5t (05/2009) 

                                                                                        OMB NO. 1513-0112 (03/31/2012) 
                                      SECTION III – BUSINESS REGISTRATION 
OWNERSHIP INFORMATION: (Check One Box Only) 
  INDIVIDUAL OWNER             PARTNERSHIP       CORPORATION    LLC                     OTHER (Specify)       
OWNERSHIP RESPONSIBILITY: (Read instruction sheet; use a separate sheet of paper if additional space is needed.) 
FULL NAME                               ADDRESS                                        POSITION 
                                                                                             
FULL NAME                               ADDRESS                                        POSITION 
                                                                                             
FULL NAME                               ADDRESS                                        POSITION 
                                                                                             
FULL NAME                               ADDRESS                                        POSITION 
                                                                                             
FULL NAME                               ADDRESS                                        POSITION 
                                                                                             
  GROSS RECEIPTS less than $500,000 (See instructions for reduced rate taxpayers on the instruction sheet) 
                                                              DATE OF COMMENCEMENT (mm/dd/yyyy) 
  NEW BUSINESS (NOTE: SHOW DATE BUSINESS COMMENCED) 
                                                                    
  EXISTING BUSINESS WITH CHANGE IN: CHECK APPROPRATE BOX BELOW 
                                                              DATE OF CHANGE (mm/dd/yyyy) 
            (a) NAME/TRADE NAME                                     
                                                              DATE OF CHANGE (mm/dd/yyyy) 
            (b) ADDRESS                                             
                                                              DATE OF CHANGE (mm/dd/yyyy) 
            (c) OWNERSHIP                                           
            (d) EMPLOYER IDENTIFICATION NUMBER                DATE OF CHANGE (mm/dd/yyyy) 
                                                                    
         (OLD:       -                ) (NEW:       -       ) 
            (e) BUSINESS TELEPHONE NUMBER                      
         (              )
                                                              DATE BUSINESS DISCONTINUED (mm/dd/yyyy) 
  DISCONTINUED BUSINESS 
                                                                    
                               PAPERWORK REDUCTION ACT NOTICE 
This request is in accordance with the Paperwork Reduction Act of 1995. This information is used to ensure compliance 
by taxpayers of P.L. 100-647, Technical Corrections Act of 1988, and the Internal Revenue Laws of the United States. 
The information collections are used to determine and collect the right amount of tax. 

The estimated average burden associated with this collection of information is .8 hour per respondent or record keeper, 
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, Washington, D.C. 20220. 

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. 

(See instructions below) 

                                                                                                TTB F 5630.5t (05/2009) 

                                                                                          OMB NO. 1513-0112 (03/31/2012) 
                                              INSTRUCTION SHEET 
 TTB FORM 5630.5t  -SPECIAL TAX REGISTRATION AND RETURN - TOBACCO 

 GENERAL INSTRUCTIONS                                             activity subject to special occupational tax).  Further, if you are 
                                                                  a member of a controlled group as defined in section 5061(e) 
If you are engaged in one or more of the tobacco activities       (3) of the Internal Revenue Code, you are not eligible for this 
listed on this form, you are required to file this form and pay   reduced rate unless the total gross receipts for the entire group 
any special (occupational) tax that is due before beginning       are less than $500,000.  If your business is beginning an 
business.  You may file one return to cover several locations or  activity subject to special tax for the first time, you may qualify 
several types of activity.  However, you must submit a separate   for a reduced rate in your initial tax year if your total gross 
return for each tax period.  The special occupational tax period  receipts for the business (or the entire controlled group, if a 
runs from July 1 through June 30 and payment is due annually      member of a control group) were under $500,000 in the 
by July 1.  If you do not pay on a timely basis, interest will be previous year.  If you are eligible for the reduced rate, check 
charged and penalties may be incurred.                            the appropriate box in Section III and compute your tax using 
The special tax rates listed on this form became effective        the reduced rate in Section III. 
January 1, 1988. If you were engaged in a tobacco related 
activity prior to this date no special occupational tax is due.   SECTION III - BUSINESS REGISTRATION 
                                                                  Please complete the ownership information in Section III.  
If you engage in a taxable activity at more than one location,    Supply the information specified for each individual owner, 
attach to your return a sheet showing your name, trade name,      partner or responsible person.  For a corporation, partnership 
address, employer identification number and the complete          or association, a responsible person is anyone with the power 
street addresses of all additional locations.                     to control the management policies or buying or selling 
 SECTION I - TAXPAYER IDENTIFYING INFORMATION                     practices pertaining to tobacco.  For a corporation, association 
                                                                  or similar organization, it also means any person owning 10 
Complete Section I, Taxpayer Identifying Information, as          percent or more of the outstanding stock in the business. 
specified on the form.  Enter the tax period covered by the 
return in the space provided.  Your return must contain a valid                    CHANGES IN OPERATIONS 
Employer Identification Number (EIN).  The EIN is a unique        If there is a change of address or location, TTB F 5630.5t must 
number for business entities issued by the Internal Revenue       be completed and submitted within 30 days of the change. All 
Service (IRS).  You must have an EIN whether you are an           taxpayers must also contact TTB National Revenue Center; 
individual owner, partnership, corporation, LLC, or a             see contact information below, in order to amend their permit 
government agency.  If you do not have an EIN, contact the        or to obtain a new one. 
Internal Revenue Service immediately to obtain one.  While 
TTB may assign a temporary identification number (beginning       If special taxpayers do not register these changes within the 
with XX) to allow initial processing of a return which lacks an   appropriate time frames, additional tax and interest will be 
EIN, do not delay submission of your return and payment           charged and penalties may be incurred.  For a change in 
pending receipt of your EIN.  If you have not received a          ownership or control of an activity, consult the TTB National 
number by the time you file this return, write "number applied    Revenue Center before beginning the activity. 
for" in the space for the number.  Submit your EIN by separate 
correspondence after receipt from the IRS.                                             SIGNING RETURN 
                                                                  This form must be signed by the individual owner, a partner, or, 
 SECTION II - TAX COMPUTATION                                     in the case of a corporation, an individual authorized to sign for 
To complete Section II, enter the number of locations in          the corporation. 
Column (d) on the appropriate line(s) and multiply by the tax 
rate, Column (c).  Insert the tax due in Column (e).  If you                       MAILING INSTRUCTIONS 
begin operations after the month of July, then you are            Please sign and date the return, make check or money order 
responsible for paying a prorated amount for the portions of the  payable to Alcohol and Tobacco Tax and Trade Bureau, for 
year you are in business.  To compute your taxes, multiply the    the amount in the Total Tax Due block, and mail the form along 
monthly rate, Column (b), by the number of locations Column       with the payment to  
(d), and then by the number of months, treating parts of 
months as whole months, from the date you commenced               SOT TAX 
operations through June 30. Insert the tax due in Column (e).     Alcohol Tobacco Tax Trade Bureau 
(For example, if you commenced operations on March 14, you        550 Main St. 
would multiply by 4.)  Compute the taxes due for each class       Ste 8002 
and enter the total amount due in the block "Total Tax Due".      Cincinnati, OH 45202-5215 
 INSTRUCTIONS FOR REDUCED RATE TAXPAYERS                                           CONTACT INFORMATION 
The reduced rates for certain taxpayer classes, indicated with    If you need further assistance contact TTB National Revenue 
an asterisk (*) in Section II, apply only to those taxpayers      Center at 1-800-937-8864 or 1-877-882-3277 or you may send 
whose total gross receipts for your most recent income tax        an email to ttbtaxstamp@ttb.gov. Additional information is also 
year are less than $500,000 (not just receipts relating to the    available at our Website, www.ttb.gov.
 
                                                                                                   TTB F 5630.5t (05/2009)