Application For Tobacco Stamping Permit Form - Alabama
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LABAMA
EPARTMENT OF
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9/08
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USINESS
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OBACCO
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P.O. Box 327555 • Montgomery, AL 36132-7555 • (334) 242-9627
Application For Tobacco Stamping Permit
(NON-RESIDENT WHOLESALER)
1. Business Name: _______________________________________________________________________________________________
2. Address: _____________________________________________________________________________________________________
3. City: _______________________________________________ State: ___________________________ Zip: ____________________
4. FEIN / SSN:
Telephone number:
/
–
5. Contact Person: _________________________________________________ Title: ________________________________________
E-Mail Address: ______________________________________________________________________________________________
6. 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.
7. List types of tobacco products you plan to distribute: ______________________________________________________________
_____________________________________________________________________________________________________________
8. 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
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