OMB No. I5I3-0055 (12/31/2014)
                      DEPARTMENT OF THE TREASURY– ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

                                      OFFER IN COMPROMISE 
                      Of Liability  ncurred I Under            the Federal Alcohol Administration Act, As Amended
      (To be filed in duplicate with the Director, National Revenue Center, Alcohol and Tobacco Tax and Trade Bureau)
TO:                                                                1. PROPONENT’S NAME AND ADDRESS         2. DATE
    DIRECTOR, NATIONAL REVENUE CENTER
    550 MAIN ST
    STE 8002
    CINCINNATI, OH  45202-5215

The following offer in compromise is submitted to you by the undersigned: 
3.  CHARGES OF VIOLATION OF THE FEDERAL ALCOHOL ADMINISTRATION ACT, AS AMENDED, HAVE BEEN MADE AGAINST THE 
PROPONENT AS FOLLOWS: (State specifically the nature of the pending charges and the sections of law and regulations alleged to have been violated)

4. TYPE OF LIABILITY (Check one)
                                                                              CIVIL                     CRIMINAL             BOTH CIVIL AND CRIMINAL
5. DATE OF VIOLATION                                               6. LOCATION OF VIOLATION

7. THE ALLEGED VIOLATION WAS DUE TO THE FOLLOWING CAUSE OR CAUSES:  (Attach a separate sheet if necessary.)

8.  TO SECURE THE RELEASE FROM THE LIABILITY RESULTING FROM THE VIOLATION OR FAILURE ABOVE                                                          REMITTANCE
SPECIFIED, THE SUM INDICATED IS OFFERED VOLUNTARILY WITH  AREQUEST THAT IT BE ACCEPTED IN                                                           $
COMPROMISE OF THAT LIABILITY. (Make remittance payable to the Alcohol and Tobacco Tax and Trade Bureau.)

9.  THE FOLLOWING FACTS AND REASONS ARE SUBMITTED AS GROUNDS FOR ACCEPTANCE OF THE OFFER. (If space provided is insufficient, 
please attach a supplemental affidavit and supporting evidence.)

TTB F 5640.2 (05/2009)                                             Page 1 of 2

        It is understood that this offer will be considered and acted upon in due course ,and that it does not relieve the proponent from the liability sought 
        to be compromised unless and until the offer is accepted in writing by the Director, National Revenue Center, or a delegated official, and there has 
        been full compliance with the terms of this offer.
        It is also understood that deposit of any remittance into the accounts of the United States Government, pending action on this offer in compromise,  
        does not constitute acceptance of the terms of this offer.
        In making this offer the proponent expressly understands and agrees that the acceptance of the offer will not in any way affect any liability 
        (civil, forfeiture ,or criminal) which he/she may have incurred by reason of violation of Federal laws other than specified in item 3 of this form, or 
        regulations issued pursuant thereto, whether or not connected with the violations herein sought to be compromised.

10. IF OFFER IS MADE BY AGENT, THE REASON MUST BE STATED IN THIS SPACE

Under penalties of perjury ,       I declare that I have examined this offer, including accompanying schedules and statements, and to the best of my 
knowledge and belief, it is true, correct, and complete.
11. SIGNATURE OF PROPONENT O RAGENT                                                     12. AGENT’S ADDRESS

                                                               PAPERWORK REDUCTION ACT NOTICE
        This request is in accordance with the Paperwork Reduction Act of 1995. This information collection is used by a person who has incurred liability 
        under the Federal Alcohol Administration Act to tender an offer in compromise in lieu of criminal and/or civil penalties. TTB examines the information 
        to determine whether to accept the offer in compromise. The information is voluntary. 
         
        The estimated average burden associated with this collection is 2 hours per respondent or recordkeeper, depending on individual circumstances.  
        Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Reports Management 
        Officer, Regulations and Rulings Division, Alcohol and Tobacco Tax and Trade Bureau, Washington, DC 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.

                                                                                                   PRIVACY ACT INFORMATION

        The following information is provided pursuant to Section 3 of the Privacy Act of 1974 (5 U.S.C. 552a(e)(3)):  
        1. AUTHORITY. Solicitation of this information is made pursuant to 27 U.S.C. 207. Disclosure of this information by the proponent is voluntary.  
        2. PURPOSE. To enable TTB to evaluate and act upon the proponent’s proposal for an offer in compromise.
        3. ROUTINE USES. The information will be used by TTB to make the determination set forth in paragraph 2. In addition, the information may be 
   disclosed to other Federal, State, foreign, and local law enforcement and regulatory agency personnel to verify information on the form where such 
   a disclosure is not prohibited by law. The information may further be disclosed to the Justice Department if it appears that the furnishing of false 
   information may constitute a violation of Federal law. Finally, the information may be disclosed to members of the public when authorized by statute 
   or regulations.
        4. EFFECT OF NOT SUPPLYING INFORMATION REQUESTED. Failure to supply complete information may prevent TTB from making an 
   informed judgement regarding the consideration of the proposed offer.  
   Disclosure of the individual’s social security number is voluntary. Under 27 U.S.C. 207, TTB has the authority to solicit this information. The social 
     security number may be used to verify the individual’s identity.  

                                                                           Page 2 of 2                                                TTB F 5640.2 (05/2009)