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Form Dr 1286 - Tobacco Distributor'S Certificate For Exemption Msa/non-Participating Manufacturer Brands - Colorado Department Of Revenue

DR 1286 (02/06/04)

COLORADO DEPARTMENT OF REVENUE

1375 SHERMAN STREET RM 208

DENVER CO 80261

(303)205-8211 EXT 6860

TOBACCO DISTRIBUTOR’S

CERTIFICATE FOR EXEMPTION

MSA/NON-PARTICIPATING MANUFACTURER BRANDS

Name of License Distributor

Colorado Account Number

Pursuant to Regulation 39-28-202(5), the Licensed Distributor (Distributor) identified above hereby

certifies that said distributor reasonably anticipates that he/she/it, will; for the twelve consecutive

months that follow the month in which the Department receives this certification:

PLEASE CHECK APPROPRIATE BOX INDICATING THE BASIS FOR EXEMPTION

Stamp and/or offer for sale in Colorado only those cigarettes, including roll-your-own tobacco

products, manufactured by participating manufacturers.

Purchase stamped cigarettes, including roll-your-own tobacco, manufactured by non-participating

manufacturers from Colorado licensed distributors.

Sell at wholesale or retail in Colorado only tobacco products not subject to the Master Settlement

Agreement. For example, cigars, pipe tobacco, chew, etc.

Said distributor further certifies that if, after filing this certificate with the Department, said distributor

stamps and/or offers for sale in Colorado cigarettes, including roll-your-own tobacco products, of a

nonparticipating manufacturer, he/she/it shall thereafter file reports with the Department as required

by Regulation 39-28-202(3). Reports must begin with the month in which such sales occur and con-

tinue unless and until such distributor files another certification.

Said distributor further certifies that he/she/it has diligently reviewed his/her/its records and, to the

best of the distributor’s knowledge and information, represents that this certification is true and accu-

rate. Further, said distributor understands that violation of the department’s regulations and statutes

may result in the revocation of the distributor’s cigarette and/or tobacco products license(s) for a

period of two years.

Date

CERTIFICATION EFFECTIVE

Name

Title

Signature

Phone Number

E-mail Address

Fax Number

Send original to: Colorado Department of Revenue, 1375 Sherman Street, Room 208, Denver, CO 80261

Retain a copy for your records.

Form Dr 1286 - Tobacco Distributor'S Certificate For Exemption Msa/non-Participating Manufacturer Brands - Colorado Department Of Revenue