Form 3371 - Stamping Agent Agreement - Michigan Department Of Treasury
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1
2Michigan Department of Treasury
3371 (Rev. 5-03)
Stamping Agent Agreement
Reset Form
Issued under authority of P.A. 327 of 1993, as amended.
Please read the instructions and responsibilities on the back of this form before completing Sections 1 or 2. The Michigan Department of Treasury will
complete Section 3.
SECTION 1
Complete the information below if you are a wholesaler or unclassified acquirer requesting authorization from the Michigan Department of Treasury to
appoint a licensed wholesaler/unclassified acquirer as your stamping agent.
Name of Wholesaler/Unclassified Acquirer
Account Number (FE, ME, or TR)
Corporate Office Address
I request authority from the Michigan Department of Treasury to appoint the name listed in Section 2 as my cigarette stamping agent
on the effective date. We have reviewed the instructions and responsibilities on the back of this form and agree to comply with those
requirements. We understand that, although the cigarette tax stamps will be affixed by our agent, the ultimate responsibility and tax
liability for the stamps lies with our company.
Print or Type Name and Title
Effective Date
Signature of Corporate Officer/Owner
Telephone Number
Signature Date
Fax Number
SECTION 2
Complete the information below if you are a licensed wholesaler or unclassified acquirer who has agreed to act as a stamping agent for the requestor.
Name of Stamping Agent
Account Number (FE, ME, or TR)
Corporate Office Address
I agree that my company will act as a cigarette tax stamping agent on the effective date. We have reviewed the instructions and
responsibilities on the back of this form and agree to comply with those requirements. We understand that, although the ultimate
responsibility lies with the cigarette tax licensee named in Section 1, we are obligated to protect the integrity of the stamps and
stamping operations for our client.
Print or Type Name and Title
Effective Date
Signature of Corporate Officer/Owner
Telephone Number
Signature Date
Fax Number
SECTION 3
Certification of Michigan Department of Treasury approval.
Signature of Treasury Official
Title
Date
After Sections 1 and 2 are complete, mail the form to:
Michigan Department of Treasury
Customer Contact Division
Tobacco Taxes Unit
Lansing, MI 48922
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