Schedule Rc-25-A - Cigarette Manufacturer/importer Certification
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Illinois Department of Revenue
Illinois Department of Revenue
Illinois Department of Revenue
Illinois Department of Revenue
Illinois Department of Revenue
Schedule RC-25-A
Cigarette Manufacturer/Importer Certification
Step 1: Identify yourself
1
2
Business name ____________________________________________________
Check the type of business you are:
❒
❒
manufacturer
importer
3
Address __________________________________________________________
Check this box if all cigarettes that you import
Number and street
into the United States comply with the
_________________________________________________________________
requirements in the perjury statement listed
❒
City
State
Country
ZIP
in Step 2:
Step 2: Sign below
Under penalties of perjury, I state that the above business has complied with the package health warning and ingredient
reporting requirements of the federal Cigarette Labeling and Advertising Act, 15 U.S.C. 1333 and 1335a; and the provisions of
Exhibit T of the Master Settlement Agreement entered in the case of People of the State of Illinois v.Philip Morris, et al. I also
state that the above business is (check one):
❒
a participating tobacco manufacturer within the meaning of Exhibit T.
❒
not a participating tobacco manufacturer within the meaning of Exhibit T.
__________________________________________________
_________________________________________________
Authorized officer signature
Printed name of the person who signed this certification
_________________________
(_____)_____ - _____________
___ ___/___ ___/___ ___ ___ ___
Title of the person signing above
Month
Day
Year
Telephone number
Reset
Print
Note:
Do not send any payment with this certification.
This form is authorized by the Cigarette Tax and Cigarette Use Tax Acts. Disclosure of this information is REQUIRED. Failure
RC-25-A front (N-6/00)
to provide information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-4128
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