Schedule Rc-25-A - Cigarette Manufacturer/importer Certification Form - 2010
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Illinois Department of Revenue
Schedule RC-25-A
Cigarette Manufacturer/Importer Certification
Step 1: Identify yourself
1
3
Business name ____________________________________________________
License no.: ___ - ___ ___ ___ ___ ___
4
Address __________________________________________________________
Check your business type:
Number and street
❒
❒
_________________________________________________________________
manufacturer
importer
City
State
Country
ZIP
❒
2
Check here if all the cigarettes you import into the United States comply with the requirements in the perjury statement listed 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 require-
ments 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
Reset
Print
*090801110*
Note:
Do not send any payment with this certification.
RC-25-A front (R-04/10)
This form is authorized by the Cigarette Tax and Cigarette Use Tax Acts. Disclosure of this information is REQUIRED. Failure
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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