Form Boe-443 - Compliance Certification
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1BOE-443 (2-04)
STATE OF CALIFORNIA
BOARD OF EQUALIZATION
COMPLIANCE CERTIFICATION
Revenue and Taxation Code Section 30165.1
Applicants for a Distributor’s License under section 30140 of the Revenue and Taxation Code must
certify they will fully comply with section 30165.1 of the Revenue and Taxation Code (copy enclosed) .
Your application will not be processed or approved if it is incomplete or submitted without the proper
certification.
Certification
The distributor identified below certifies that it will comply fully with Revenue & Taxation Code section
30165.1 and acknowledges and understands that any person who makes this certification and
asserts the truth of any material matter that he or she knows to be false is guilty of a misdemeanor
punishable by imprisonment of up to one year in county jail, or a fine of not more than $1,000, or both
the fine and imprisonment.
Note: This form must be signed by an owner, partner, corporate officer, LLC member or manager, or
by an authorized agent. For a partnership, attach authorization signed by all general partners; for a
corporation, attach corporate resolution; and for a LLC, attach articles of organization which authorize
the individual who signs below to make this certification. If signed by an authorized agent, a properly
completed power of attorney must be attached to this certification.
DISTRIBUTOR NAME
ADDRESS
NAME OF PERSON AUTHORIZED TO SIGN (typed or printed)
TITLE
SIGNATURE OF PERSON AUTHORIZED TO SIGN
DATE
✍
CLEAR
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