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ONSUMPTION OR ALCOHOLIC BEVERAGES Taxpayer's Name Social Security Number Merchant's Registration Number Bond Number Postal Address Physical Address Amount Zip Code Telephone Number - Extension ( ) E-mail WHEREAS, the above taxpayer, pursuant to the provisions of the PUERTO RICO INTERNAL REVENUE CODE OF 1994, ACT 120 OF OCTOBER 31, 1994, AS AMENDED, OR THE INTERNAL REVENUE CODE FOR A NEW PUERTO RICO, ACT 1 OF JANUARY 31, 2011, AS AMENDED, requests to the Secretary of the Treasury for per.

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