SD EForm - 1357
V1
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Tobacco Distributor License Application
TD-
Mail To: SD Department of Revenue, Special Tax Division, 445 E Capitol Ave, Pierre, SD 57501-3100
A. Applicant’s Name & Address
B. Business Name & Address
C. License being applied for:
D. Legal Description of Licensed Premise
Tobacco Distributor - $150.00
Transfer - $2.50
License Information:
A.
Distributors must purchase at least 75%, of cigarettes handled, directly from manufacturers.
B.
A separate license must be obtained for each wholesale or distribution outlet.
C.
Cigarette stamps can only be sold to licensed distributors.
D.
License fee for January - June is $75.00 / License fee for July - June is $150.00
License Questionnaire:
The percentage of cigarettes purchased directly from manufacturer during the last 12 months ____________________%.
If a new licensee - the percentage of cigarettes planned on buying from a manufacturer _________________%.
Yes
No
1. Do you operate more than one distribution or wholesale outlet?
2. Do you maintain separate wholesale warehouses?
3. Do you service retail outlets?
Number of retail outlets serviced
4. Do you own any retail outlets?
Number of retail outlets owned
5. Do you service cigarette vending machines?
Number of cigarette vending machines serviced
6. Do you own any of the cigarette vending machines you service?
Number of cigarette vending machines owned
7. Will you provide name, address and location of any retail outlet or any vending machine
outlets you serve when requested to do so by the Department of Revenue?
I declare under the penalties of perjury that all statements made in connection with this application are true and correct to the best of my knowledge and belief.
I agree that the Secretary and his authorized agents may examine the books, papers and records of the applicant-licensee for the purpose of determining
whether the tax imposed by SDCL 10-50 has been fully paid, and may investigate and examine the stock of cigarettes or other tobacco products in or upon the
premises or any premises where such cigarettes or other tobacco products are possessed, stored, or sold for the purpose of determining whether the provision of
10-50 are being obeyed. Such inspection and examination may be made at any time during ordinary business hours, and may inspect at such times the
premises and all desks, safes, vaults, and other fixtures and furniture contained in or upon such premises for the purposes of ascertaining whether cigarettes or
other tobacco products are held or possessed in violation of SDCL 10-50.
Date of Application
Signature of Applicant
SPT 301 03-99
DEPARTMENT OF REVENUE USE ONLY
Amount of fee forwarded with application
Date Received
Approved by
Date Issued
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1.
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