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MISSOURI DEPARTMENT OF REVENUE
TAXATION BUREAU
FORM
• PLEASE USE THIS FORM TO MAKE CHANGES
P.O. BOX 811, JEFFERSON CITY, MO 65105-0811
4732
IN YOUR REGISTRATION RECORDS
CIGARETTE / OTHER TOBACCO PRODUCTS
• PLEASE PRINT OR TYPE
(REV. 5-2007)
REGISTRATION CHANGE REQUEST
MISSOURI CIGARETTE/OTHER
BUSINESS NAME CURRENTLY ON FILE
TOBACCO PRODUCTS TAX ID NO.
BUSINESS ADDRESS CURRENTLY ON FILE
PLEASE MAKE THE FOLLOWING CHANGE(S) IN MY REGISTRATION RECORDS: (CHECK AND COMPLETE APPROPRIATE ITEMS)
1.
CHANGE BUSINESS NAME TO:
NAME
D/B/A
2.
CHANGE FEDERAL IDENTIFICATION NUMBER TO:
3.
CHANGE TYPE OF OWNERSHIP TO:
2
3
4
SOLE OWNER
PARTNERSHIP
GOVERNMENT
OTHER
1
MISSOURI CERTIFICATE OF AUTHORITY NUMBER
5
6
MISSOURI CORPORATION
CORPORATION
MISSOURI FICTITIOUS NAME NUMBER
FEIN NUMBER
FICTITIOUS NAME BUSINESSES:
4.
CHANGE OWNER NAME TO: (USE ONLY IF CHANGE RESULTS FROM CHANGE IN TYPE OF OWNERSHIP. IF OWNER
NAME CHANGES DUE TO TRANSFER OR SALE, ETC., A NEW APPLICATION MUST BE COMPLETED)
NEW LEGAL NAME OF OWNER
CURRENT PHONE NUMBER
OWNER SOCIAL SECURITY NUMBER
BIRTHDATE (MMDDCCYY)
–
–
IF SOLE PROPRIETOR:
5.
CHANGE OF PARTNERS IN A CORPORATION:
(ATTACH SUPPLEMENTAL LIST OF DELETIONS AND ADDITIONS, IF NECESSARY)
DELETE:
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NUMBER
BIRTHDATE (MMDDCCYY)
STREET ADDRESS
CITY
STATE
ZIP CODE
ADD:
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NUMBER
BIRTHDATE (MMDDCCYY)
STREET ADDRESS
CITY
STATE
ZIP CODE
6.
CHANGE PHYSICAL LOCATION TO:
STREET ADDRESS
CITY
STATE
ZIP CODE
COUNTY
7.
CHANGE ADDRESS WHERE REPORTING FORMS ARE TO BE MAILED:
STREET ADDRESS
CITY
STATE
ZIP CODE
COUNTY
8.
CHANGE ADDRESS WHERE BOOKS AND RECORDS ARE KEPT:
STREET ADDRESS
CITY
STATE
ZIP CODE
COUNTY
9.
ATTACH ORIGINAL RIDER FROM BONDING COMPANY COVERING CHANGE OF NAME AND/OR ADDRESS
10.
A NEW BOND INDICATING CHANGE OF OWNERSHIP ACCOMPANIED BY NEW APPLICATION
OWNER OR AUTHORIZED PERSON
TITLE
DATE
If you have questions or need assistance in completing this form, please call (573) 751-7163 or e-mail excise@dor.mo.gov. You may also access the department’s
web site at TDD: (800) 735-2966
This publication is available upon request in alternative accessible format(s).
MO 860-2807 (5-2007)