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Missouri Department of Revenue
Missouri Tobacco Directory -
Form
5304
Non-Participating Manufacturer Certification
Postmark Date (MM/DD/YYYY):
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Complete a separate form for each liability year for which you are certifying (select one)
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Current calendar year for this certification:
20______
Type of Certification (select one):
Initial
Annual
Supplemental
Company Name
Federal Identification Number
Mailing Address
City
State
Zip Code
Country
Physical Address
City
State
Zip Code
Country
Telephone Number
Fax Number
E-mail Address
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Missouri Statute
32.057,
RSMo, states that all tax records and information maintained by the Missouri Department of Revenue are confidential. The tax
information can only be given to the owner, partner, member, or officer who is listed with us as such. If you wish to give an employee, attorney, or accountant
access to your tax information, you must supply us with a power of attorney giving us the authority to release confidential information to them.
Contact Person for Certification - Must be owner or officer. If not, Power of Attorney must be completed.
Telephone Number
Name
Title
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Power of Attorney Attach a completed
Form
2827.
E-mail Address
Plant Name
Plant Telephone Number
Plant Fax Number
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Physical Address
City
State
Zip Code
Country
Name and Title of Contact Person at Plant (if different than above)
The undersigned certifies that as of the date of this Certification, the above-named company is a Non-Participating Tobacco Products
Manufacturer in full compliance with
196.1000
to
196.1003,
RSMo, including having made all required payments into a Qualified Escrow Fund
as defined in 196.1000(f), RSMo. The company qualifies as a Non-Participating Tobacco Product Manufacturer because (select all that apply):
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The company is the fabricator of the listed brands in this Certification which are intended to be sold in the United States including cigarettes and
Roll Your Own (RYO) intended to be sold in the United States through an importer.
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The company is the first purchaser anywhere for resale in the United States of cigarettes and RYO manufactured anywhere that the manufacturer
does not intend to be sold in the United States. If yes, provide the name, plant address, contact person, phone and fax number of the fabricator.
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The company is a successor of any entity described above (i.e. manufacturer or first importer). If yes, provide the name, plant address,
contact person, telephone number and fax number for the entity this company is succeeding.
U.S. Treasury, Tobacco Tax Bureau (TTB) Permit Number
Last Year Permit or License Issued
Foreign Manufacturer Permit Number (if applicable)
Last Year Permit or License Issued
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P
rovide a copy of current permit.
Attached
A. Brand Family and Brand Style: For each brand style which the company requests for certification or for which the company received
certification in a prior year, the following information is to be provided on the Form 5303 Missouri Tobacco Directory - Non-Participating
Manufacturer Brands Certification:
• Name: List all brand families and styles as follows - brand family, brand style, flavor, size, and container. Those brand styles that will not
be sold in the current year should be marked with an asterisk(*).
• Cigarette or Roll-Your-Own (RYO): Indicate whether the product is a cigarette or RYO.
• Packaging Submitted: Indicate if packaging sample is being submitted.
• Current Manufacturer: Include the name and address of the current manufacturer.
• Prior Manufacturer(s): Include the name and address of all prior manufacturers.
• Units Sold - Prior Year: Indicate the number of units sold during the prior calendar year.
• Units Sold - Current Year To Date: Indicate the number of units sold during the current calendar year.
• Current Trademark Holder: Include the name and address of the current trademark holder.
• Prior Trademark Holder: Include the name and address of all prior trademark holders.
Form 5304 (Revised 01-2015)