Form Cig 23 - Application To Use Cigarette Fuson Tax Stamps
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1CIG 23
Rev. 7/10
P.O. Box 530
Columbus, OH
43216-0530
Application to Use Cigarette Fuson Tax Stamps
Name of business
FEIN
DBA
Social Security number
Street
Telephone number
(
)
City
State
ZIP code
1. E-mail address (required)
2. Business structure:
Sole owner
Partnership
Corporation
Fiduciary
Association
LLC
LLP Other
3. List cigarette manufacturers/importers selling unstamped cigarettes to your company
4. List below the titles, names, addresses and Social Security numbers of all corporate offi cers or association offi cers or
partners. If you need more space to complete the list, please attach a sheet with the requested information.
Title
Name
Address
Social Security No.
Federal Privacy Act
5703.05, 5703.057 and 5747.08 authorize us to request
Because we require you to provide us with a Social Se-
this information. We need your Social Security number in
curity number, the Federal Privacy Act of 1974 requires
order to administer this tax.
us to inform you that providing us with your Social Secu-
rity number is mandatory. Ohio Revised Code sections
I declare under penalties of perjury that the above statements have been examined by me and to the best of my knowledge
and belief are true, complete and correct.
Signature
Title
Date
Mail this application to the Ohio Department of Taxation, Excise Tax Unit, P.O. Box 530, Columbus, Ohio 43216-0530, with
the following items:
1. A letter of intent (or invoice if already purchasing) from a manufacturer/importer to sell unstamped cigarettes to your
company.
2. A completed bond form for the purchase of cigarette tax stamps on credit (optional).
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