Form 5300 - Non-Participating Manufacturer'S (Npm) Appointment Of Registered Agent For The State Of Missouri

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Missouri Department of Revenue
Form
Non-Participating Manufacturer’s (NPM) Appointment
5300
of Registered Agent For The State Of Missouri
The undersigned Non-Participating Manufacturer (NPM) _____________________________________________________
hereby appoints and authorizes _________________________________________________________________________
as its registered agent to receive service of process on our behalf. The undersigned NPM agrees to provide notice to the
Director of Revenue, at least 30 days prior to termination of the authority of the registered agent, and to provide
proof to the satisfaction of the Director of Revenue of the appointment of a new agent at least five calendar days prior to the
termination of an existing agent agreement.
Under penalty of perjury, I certify and declare that all of the statements and information contained in this Certification,
including but not limited to any accompanying statements or attachments herewith, are true, accurate and complete
in every particular and that I am a person authorized to bind the NPM making the Certification either under the laws of
the state of Missouri or of the jurisdiction where the manufacturer resides or is organized. Any violation of the
requirements of
Section 196.1026,
RSMo, is a basis for removal of the applicant’s brand families from Missouri’s Directory of
Compliant Tobacco Products Manufacturers. Brand families that are not listed on Missouri’s Directory of Compliant Tobacco
Products Manufacturers are not eligible to be sold in the state of Missouri.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Signature Of Authorized Person For Non-Participating Manufacturer
Title
Authorized Person Printed Name
Date Signed (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Principal Place of Business (Physical Address)
City
State
ZIP Code
Form 5300 (Revised 01-2015)
Mail to: Taxation Division
and
Missouri Attorney General
Phone: (573) 751-7163
P.O. Box 811
P.O. Box 899
Fax: (573) 522-1720
Jefferson City, MO 65105-0811
Jefferson City, MO 65102-0899
TTY: (800) 735-2966
tobacco.certification@ago.mo.gov
E-mail:
excise@dor.mo.gov
Visit
for additional information.

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