Form Otp-1 - Application For Other Tobacco Products Distributor License - State Of Ohio - 2002
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1OTP Tax Form
OTP-1 (Rev. 2/02)
P.O. Box 530= Columbus, OH 43216-0530
Application for Other Tobacco Products Distributor License
For the period February 1, 20_____ to January 31, 20_____
Name of Business
FEIN
DBA
Social Security No.
Street
City
State
Zip Code
Telephone Number
(
)
1. Mailing address if different from above: ______________________________________________________________
______________________________________________________________________________________________
2. Business Structure:
c
c
c
c
c
c
Sole Owner
Partnership
Corporation
Fiduciary
Association
Other
3. Type of Business:
c
c
c
c
Wholesale
Retail
Broker
Importer
4. List below the titles, names and addresses of all corporate officers, association officers or partners.
Title
Name
Address
Social Security No.
Federal Privacy Act
Because we are requesting your social security account number, the Fed-
is needed for the Tax Commissioner to administer this tax. Failure to
eral Privacy Act of 1974 requires us to inform you that giving us your social
supply any information requested on a tax form prescribed by the Tax
security number is mandatory. Our legal right to ask for this information is
Commissioner may result in the denial of your license application, if appli-
supported under the Tax Reform Act of 1986. Your social security number
cable, or the imposition of penalties for failing to file a complete tax return.
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 ______________
A separate application is required for each business location. This is an annual license which must be renewed by the first of February
each year. Mail application and $100.00 application fee to the Ohio Department of Taxation, Excise Tax & Assessment Unit, P.O. Box
530, Columbus, OH 43216-0530.
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