Form FDA 3852 FDA 3852 Report of Tobacco Product Removals Subject to Tax

Form Approved: OMB No. 0910-0749
Expiration Date: xx/xx/201x
(See Burden Statement on page 2)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration
Center for Tobacco Products

Report of Tobacco Product Removals Subject to Tax
for Tobacco Product User Fee Assessments

(Section 919 of FFDCA; Title 21, Code of Federal Regulations, Part 1150)
Return this completed form and copies of supporting
documents (TTB Forms 5210.5 and 5000.24 and
Customs CBP Form 7501, as appropriate) by mail to:

The authority for collecting the following information
is section 301 et seq. of the Federal Food, Drug,
and Cosmetic Act. The information will be used to
assess and collect user fees from tobacco product
domestic manufacturers and importers. Please be
advised that under section 1001 of title 18 anyone
who makes a materially false, fictitious, or
fraudulent statement is subject to criminal penalties.
1. Company Name/Address (including Zip Code)

Center for Tobacco Products,
Food and Drug Administration,
9200 Corporate Boulevard,
Attn: Document Control Center,
Rockville, MD 20850-3229.
or to TOBACCOUSERFEES@fda.hhs.gov
Alternate Company Address (if any, for FDA notifications)

2. Contact Person Name

3. TTB Permit Number

4. Telephone Number (including Area Code)

5. Employer Identification Number

6. Email

Privacy Act Notice:
This notice is provided pursuant to the Privacy Act of 1974, 5 U.S.C. 552a. The collection of this information is
authorized by 21 U.S.C. 371, 379, 379e, 379h, 379h-1, 379j, 379j-12, 379j-21, 387s, and 393(d)(2); 42 U.S.C.
263b(r)(1); 5 U.S.C. 301 and 552; and 42 U.S.C. 3101. FDA will use the information to assess, collect and process
user fee payments, and, facilitate debt collection under the Debt Collection Improvement Act. FDA may disclose
information to courts and the Department of Justice in the context of litigation and requests for legal advice; to
other Federal agencies in response to subpoenas issued by such agencies; to HHS and FDA employees and
contractors to perform user fee services; to the National Archives and Records Administration and General
Services Administration for records management inspections; to the Department of Homeland Security and other
Federal agencies and contractors in order to respond to system breaches; to banks in order to process payment
made by credit card; to Dun and Bradstreet to validate submitter contact information, and to other entities as
permitted under the Debt Collection Improvement Act. Furnishing the requested information is mandatory.
Failure to supply the information could prevent FDA from processing user fee payments. Additional detail regarding
FDA’s use of information is available online: http://www.fda.gov/RegulatoryInformation/FOI/PrivacyAct/default.
htm, and http://www.fda.gov/AboutFDA/AboutThisWebsite/WebsitePolicies/default.htm.
7. Period of Activity

A. Month: B. Year:

FORM FDA 3852 (1/14)

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PSC Publishing Services (301) 443-6740

EF

Report of Tobacco Product Removals Subject to Tax
Domestic Taxable Removals
Volume (Number or Pounds)

Taxes (Dollars)

TTB 5210.5
Monthly Manufacturer Report

TTB 5000.24
Excise Tax Return

Imports
Volume (Number or Pounds)

Taxes (Dollars)

Customs CBP 7501
Importer Entry Summary

8. CIGARETTES
Line 14
Columns C + D

Line 13
Column B

Box 31- Monthly Total

Box 38 - Monthly Total

Line 15 Column B

Box 31- Monthly Total

Box 38 - Monthly Total

(Number of Cigarettes)

(Taxes on Cigarettes Only)

9. SNUFF
Line 14
Column F

(Snuff Only)

(Pounds of Snuff)

(Taxes on Snuff Only)

10. CHEWING TOBACCO
Line 14
Column E

Box 31- Monthly Total

Line 15 Column B

(Chewing Tobacco Only)

(Pounds of Chewing Tobacco)

Box 38 - Monthly Total

(Taxes on Chewing Tobacco Only)

11. ROLL-YOUR-OWN TOBACCO
Line 14
Column H

Line 16 Column B

(Roll-Your-Own Tobacco Only)

Box 31- Monthly Total

(Pounds of Roll-Your-Own Tobacco)

Box 38 - Monthly Total

(Taxes on Roll-Your-Own Tobacco Only)

CERTIFICATION
I hereby certify that the information on this form is true and correct, and that I am hereby authorized to submit this form on the company’s behalf.

Signature (Print and Sign)

Title

Date Prepared (mm/dd/yyyy)

This section applies only to requirements of the Paperwork Reduction Act of 1995.
*DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.*
The burden time for this collection of information is estimated to average 4 hours per response, including the
time to review instructions, search existing data sources, gather and maintain the data needed and complete
and review the collection of information. Send comments regarding this burden estimate or any other aspect of
this information collection, including suggestions for reducing this burden, to the following address:
Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer
Paperwork Reduction Act (PRA) Staff
PRASTAFF@fda.hhs.gov

FORM FDA 3852 (1/14)

“An agency may not conduct or sponsor,
and a person is not required to respond to,
a collection of information unless it displays
a currently valid OMB number.”

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