Form Dr 0222 - Cigarette Tax/tobacco Products Distributor Application - 2003
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1DR 0222 (09/03)
COLORADO DEPARTMENT OF REVENUE
BUSINESS TAX ACCOUNTING SECTION
1375 SHERMAN ST
DENVER CO 80261
(303) 205-8211 EXT. 6860
Cigarette Tax/ Tobacco Products
Distributor Application
This form is to be used for new distributors only.
DO NOT WRITE IN THIS SPACE
Type of Ownership
Registration Number
INDIVIDUAL
GENERAL PARTNERSHIP
OTHER (specify):
CORPORATION
LIMITED PARTNERSHIP
_______________________________
Taxpayer Name (owner, partners or corporation) (last, first, middle)
Trade Name/Doing Business As (if applicable)
Address of Principal Place of Business (street)
City
State
ZIP
Telephone
(
)
Mailing Address (if different from above) (street or PO Box) City
State
ZIP
Telephone
FEIN/SSN
First Day of Business
•
(
)
CIGARETTE TAX
LICENSE
Required if applicant will be:
PURCHASING AND AFFIXING TAX STAMPS TO PACKS OF CIGARETTES
OFFERING STAMPED CIGARETTES TO RETAILERS
Cigarette tax license not required for retail sales of cigarettes to end consumer.
TOBACCO PRODUCTS
LICENSE
Required if the applicant is the:
FIRST TO RECEIVE TOBACCO PRODUCTS IN THE STATE
PRIMARILY RESPONSIBLE FOR THE TOBACCO PRODUCTS TAX
PURCHASE TOBACCO PRODUCTS FROM MANUFACTURER OR UNLICENSED OUT-OF STATE WHOLESALER.
Tobacco products license not required for retail sales to end consumer if products are purchased from licensed
Colorado wholesalers.
FEE SCHEDULE
The license fee is based on a fiscal year beginning July 1 and ending June 30. If opening date of the business occurs:
JULY
OCTOBER
JANUARY
APRIL
Cigarette License Fee
$
0820-750
(999)
AUGUST
NOVEMBER
FEBRUARY
MAY
SEPTEMBER
DECEMBER
MARCH
JUNE
Tobacco License Fee
$
0920-750
(999)
$
FEE: $10.00
FEE: $7.50
FEE: $5.00
FEE: $2.50
TOTAL REMITTED
The applicant agrees that upon acceptance of the license granted by the department for cigarette tax and/or tobacco products, that they
are subject to all provisions of the following statutes and regulations: C.R.S., Title 39, Article 28, Part 1, Cigarette Tax, Title 39, Article
28, Part 2 - Tobacco Escrow Funds, Title 39, Article 28, Part 3- Additional requirements for tobacco product manufacturers and stamping
agents. Title 39, Article 28.5, Tobacco Products. Non-compliance with these statutes and regulations can result in revocation of the
license(s) for two years. The statutes are available for review at
I declare under penalty of perjury in the second degree that the statements made in this application are true and complete to
the best of my knowledge. (Signature required below.)
Type or Print Authorized Signature
Title
Signature of Owner, Partner, or Corporate Officer
Date
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