JEFFREY MAPLE
SUZANNE MAPLE
123 Pear Lane
Anyplace, VA 20000
PAY TO THE
ORDER OF
ANYPLACE BANK
Anyplace, VA 2000
For
1234
15-0000/0000
DOLLARS
25025002
20202086
Routing
number
ITEM 10a
Account
number
ITEM 10c
$
1234
Do not include the
check number
ITEM 1. Enter the section of the regulations under which you are
filing this claim. You may refer to regulations listed on the
TTB website at http://www.ttb.gov.
ITEM 2. Select the type of claim you are filing as follows (Note: The
following are general definitions. Please review regulations
for further information on filing claims for your commodity):
REMISSION OF TAX - A qualified permittee, manufacturer,
or proprietor may file a claim for remission of tax on the
quantity of distilled spirits, (including distilling material and
denatured spirits) or tobacco products that were lost or
destroyed while in bond, if the tax has not been paid or
determined. A claim of this type may also be filed to cover
underpaid beer lost in transit between breweries and
underpaid wine removed for export, but lost while in
transit to the point of export.
Note: This type of claim may be filed only by the person
who is liable for paying the tax.
ALLOWANCE OF LOSS - A qualified permittee,
manufacturer, or proprietor may file a claim for allowance
of loss or relief of tax liability on denatured spirits, wine, or
beer that have been lost or destroyed on the bonded
premises. Or wine lost or destroyed in transit thereto, if the
tax has not been paid or determined.
Note: Tax paid distilled spirits, wine, beer, or tobacco
products which are lost or rendered
unmerchanta
ble by accident, disaster, fire, casualty,
or act of God should be filed as a claim for
allowance of credit or claim for refund.
DRAWBACK – MNBP – A manufacturer of nonbeverage
products may file a claim for drawback on distilled spirits
used in a TTB approved formula for use as a medicine,
medicinal preparation, food product, flavor, flavor extract, or
any other TTB approved nonbeverage product. Formulas
which are stated in the current revisions or editions of the
United States Pharmacopoeia (U.S.P.), the National
Formulary (N.F.), or the Homeopathic Pharmacopoeia of
the United States (H.P.U.S.) are considered approved
formulas.
ALLOWANCE OF CREDIT - A qualified permitted,
manufacturer, or proprietor may file a claim for allowance
of credit of tax. The approved amount may be applied as
credit toward unpaid taxes or future tax liabilities.
ALLOWANCE OF TAX - A tobacco manufacturer, export
warehouse proprietor, or permittee may file a claim for relief
from thepayment of tax on tobacco products, if after
determination of tax and removal from the factory, but prior
to the time for payment of the tax, the articles are lost (other
than by theft) or destroyed by fire, casualty, or act of God.
DRAWBACK- EXPORT - A qualified winery, distilled spirits
plant, brewery, or tobacco manufacturer may file a claim for
drawback of the tax on taxpaid spirits, wine or beer exported
from the United States. This type of claim cannot be used for
tobacco products exported with the benefit of drawback.
ABATEMENT OF TAX - A claim for abatement of tax on
firearms, ammunition, distilled spirits, wines, beer, or
tobacco products may be filed if the tax is assessed or has
been assessed excessively and the taxpayer believes that
the tax, or any portion of the tax, is not due.
REFUND OF TAX - A claim may be filed by a taxpayer for
a refund of taxes illegally, erroneously, or excessively
collected. The claim must be filed within three years (two
years under certain circumstances) after the date the tax is
due, or paid, whichever is later.
ITEM 3. Enter the claimant's name and address. (Telephone number
and e-mail address are optional)
ITEM 4. Enter the claimant’s employer identification number.
ITEM 5. Enter the claimant’s plant, license, or registry number.
ITEM 6. Enter the kind of tax (excise tax, special tax)
ITEM 7 Enter the period of which the tax was due (this only
applies to special tax or nonbeverage claims). Enter the
mm/dd/yy format.
ITEM 8. Enter the total am
ount of tax bein
g claimed.
ITEM 9.
Enter the dat
e the tax was paid (if paid) by the claimant.
ITEM 10. Direct Deposit is a safe and secure way to have your refund
deposited automatically.
ITEM 10a. The routing number mu
st be nine digits. On the sample check
below, the routing number is 250250025.
ITEM 10b. Check the appropriate box for the type of account. Do not
check more than one box.
ITEM 10c. The account number can be up to 17 characters (both
numbers and letters). Include hyphens but omit spaces and
special symbols. On the sample check below, the account
number is 20202086.
ITEM 11. Provide detailed information that may be required by the
applicable regulations pertaining to the claim along with any
other necessary facts. Also identify any documents or
statements submitted to support the claim.
ITEM 12. Enter the signature and title of a person authorized to sign
on behalf of the company/claimant. The name of the person
signing the claim should be typed or legibly printed under or
beside the signature.
ITEM 13. Enter the date the claim was signed.
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