Form Dp-31 - Application For Tobacco Tax License - New Hampshire
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1
2NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
FORM
DP-31
APPLICATION FOR TOBACCO TAX LICENSE
MANUFACTURERS, SUB-JOBBERS, & WHOLESALERS
065
Check A or B as applicable.
LIC #
A
B
LICENSE RENEWAL
NEW LICENSE
ISSUED BY
DATE
C
TOBACCO PRODUCTS SOLD
Cigarettes
Loose
Smokeless
Cigars
Other: __________________
PRINT OR TYPE
NAME OF LEGAL ENTITY/OWNER
BUSINESS NAME (DBA)
1
2
NH BUSINESS ADDRESS NUMBER & STREET, CITY/TOWN, STATE AND ZIP CODE+4
BUSINESS PHONE
3
4
MAILING ADDRESS (IF DIFFERENT THAN #3)
NUMBER & STREET, CITY/TOWN, STATE AND ZIP CODE+4
5
FORMER OWNER NAME
PURCHASE DATE
7
6
8 TYPE OF BUSINESS ENTITY & TAX IDENTIFICATION NUMBER (SSN/FEIN/DIN) CHECK ONE:
2
1
CORPORATION
PROPRIETORSHIP
SOCIAL SECURITY NUMBER (SSN)
3
PARTNERSHIP
FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) OR
Proprietorships MUST enter SSN
DEPARTMENT IDENTIFICATION NUMBER (DIN)
SMLLC/LLC
8(b) List the names of all individuals/entities from whom you buy tobacco products (attach separate sheet if additional space is needed):
9 INDIVIDUAL OWNERS, OFFICERS, OR MEMBERS
10 LICENSE FEES
MANUFACTURER
Fee is $100.00 ........................... $
NAME
TITLE
SUB-JOBBER
Fee is $150.00 ........................... $
SSN
CONTACT TELEPHONE
WHOLESALER
Fee is $250.00 ........................... $
ADDRESS
10 TOTAL AMOUNT ENCLOSED .......................................$
CITY/TOWN, STATE, ZIP CODE+4
Make check payable to: STATE OF NEW HAMPSHIRE
The appropriate fee(s), as listed in Line 10, must accompany this form.
NAME
TITLE
SSN
CONTACT TELEPHONE
MAIL
NH DRA
PO BOX 637
TO:
ADDRESS
CONCORD, NEW HAMPSHIRE 03302-0637
CITY/TOWN, STATE, ZIP CODE+4
Attach a list of any additional owners, offi cers or members.
11.
RSA 78:6-a requires the Commissioner to consider certain information prior to issuing or renewing a tobacco tax license.
11a. Has the applicant previously had a NH Tobacco Tax License revoked under RSA 78:6? ___Yes ___No
11b. Does the applicant owe any Tobacco Tax to the State of NH under this or any other tobacco tax license? ___Yes ___No
11c.
Has the applicant been convicted of a crime related to Tobacco Tax in this or any state within the last year? ___Yes ___No
FOR DRA USE ONLY
This application must be signed, in ink, and dated by an offi cer/owner/member.
I understand a return must be fi led for each month in which my license is active. Under penalties of perjury, I declare that I have
examined this document and to the best of my belief the information herein is true, correct and complete. If signed by a corporate
offi cer, partner or fi duciary on behalf of the wholesaler, manufacturer or subjobber, I certify that I have the authority to direct the
above changes.
X
12
SIGNATURE (IN INK)
PRINT SIGNATORY NAME & TITLE
DATE
DP-31
Page 1
Rev. 4/2010
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