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LABAMA
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P.O. Box 327555 • Montgomery, AL 36132-7555 • (334) 242-9627
Application For Tobacco Stamping Permit
(RESIDENT WHOLESALER)
TO THE ALABAMA DEPARTMENT OF REVENUE:
1. We, ______________________________________________________________________________, whose place of business is
COMPANY NAME
located at ______________________________________________________________________________________________, in
STREET ADDRESS
_______________________________, Alabama __________________ do hereby apply for a wholesaler’s or jobber’s permit as
CITY
ZIP
required by Code of Alabama 1975, Section 40-25-16. If permit is issued, we agree not to pass on any part of the seven and
one-half percent discount allowed by the State on the purchase of stamps. We also furnish the following information:
2. FEIN / SSN:
Telephone number:
/
–
3. Contact Person: _________________________________________________ Title: ________________________________________
E-Mail Address: ______________________________________________________________________________________________
4. Type of Business Entity:
Individually Owned
Partnership
Corporation
Limited Liability Co. (LLC)
Other ________________
List below the names, identifying number (social security or FEIN number), and address of all owners, partners, corporate
officers, and LLC members. Attach additional sheets if space is not sufficient.
NAME
SSN/FEIN (Identifying #)
TITLE
HOME ADDRESS
If you are a LLC, are you a
single-member or
multi-member.
For Federal income tax purposes, have you filed Internal Revenue Service (IRS) form 8832 electing to be treated as a
corporation?
Yes
No If yes, please attach a copy to this form.
5. List types of tobacco products you plan to distribute: ________________________________________________________________
_______________________________________________________________________________________________________________
6. The Tobacco Master Settlement Complementary Legislation Act requires wholesalers and distributors to submit reports to
the Alabama Department of Revenue that show the total number of cigarettes or in the case of roll-your-own, the equivalent
stick count for which the wholesalers and distributors affixed stamps during the previous month or otherwise paid the tax
due. It is unlawful for a wholesaler or distributor to stamp, sell, offer, or possess for sale cigarettes that are manufactured by a
manufacturer that is not in full compliance with this Act. A wholesaler or distributor can lose their stamping privileges or
registration number if they have activity with a manufacturer that is not in full compliance with the above Act and the NPM
Escrow Provisions of Title 6, Chapter 12. Pursuant to the above Act, the statement below must be signed and notarized in
order to complete the application process.
Under penalties of perjury, we hereby certify that we will comply fully with the provisions of the Tobacco Master Settlement
Complementary Legislation Act.
Firm: ________________________________________________________________________________________________________
Signature: ____________________________________________________________________________________________________
OVER