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Get Omb No. 1513-0131 (09/30/ 2012 ) Department Of The - Ttb.gov

TION PORT OF SERIAL NO. OF PACKAGE (a) TAX PAID AT DISTILLED SPIRITS PLANT NO. (b) OPERATED BY (c) PROOF GALLONS (d) PROOF AMOUNT OF TAX DATE WITHDRAWN (e) (f) (g) 3. I certify that no other certificate covering the above-described alcohol has been issued. This certificate is issued at the request of to be used at the port of on account of drawback on certain flavoring extracts, and/or medicinal or toilet preparations claimed to have been manufactured by with the use of the above-des.

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