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Form Dr 1286 - Tobacco Distributor'S Certificate For Exemption Msa/non-Participating Manufacturer Brands

DR 1286

Colorado Department of Revenue

Business Tax Accounting Section

1375 Sherman Street

Denver, CO 80261

(303) 205-8211, Ext. 6860

TOBACCO DISTRIBUTOR’S

CERTIFICATE FOR EXEMPTION

MSA/NON-PARTICIPATING MANUFACTURER BRANDS

Name of Licensed Distributor: ________________________________

Colorado Account No.:

_____________________

Pursuant to Regulation 39-28-202(5), the Licensed Distributor (Distributor) identified above hereby certifies

that said distributor reasonably anticipates that he/she/it, will; for the twelve consecutive months that follow

the month in which the Department receives this certification:

LEASE CHECK APPROPRIATE BOX INDICATING THE BASIS FOR EXEMPTION

Stamp and offer for sale in Colorado only those cigarettes, including roll-your-own tobacco

products, manufactured by participating manufacturers.

Purchase stamped cigarettes, including roll-your-own tobacco, manufactured by non-participating

manufacturers from Colorado licensed distributors.

Sell at wholesale or retail in Colorado only tobacco products not subject to the Master Settlement

Agreement. For example, cigars, pipe tobacco, chew, etc.

Said distributor further certifies that if, after filing this certificate with the Department, said distributor

stamps and/or offers for sale in Colorado cigarettes, including roll-your-own tobacco products, of a non-

participating manufacturer, he/she/it shall thereafter file reports with the Department as required by

Regulation 39-28-202(3). Reports must begin with the month in which such sales occur and continue unless

and until such distributor files another certification.

Said distributor further certifies that he/she/it has diligently reviewed his/her/its records and, to the best of

the distributor’s knowledge and information, represents that this certification is true and accurate. Further,

said distributor understands that violation of the department’s regulations and statutes may result in the

revocation of the distributor’s cigarette and/or tobacco products license(s) for a period of two years.

CERTIFICATION EFFECTIVE: ______________

(DATE)

______________________________________

Title______________________________

Signature

Name _________________________________

Telephone No.:______________________

(Please Print)

Send original to: Colorado Department of Revenue, 1375 Sherman Street, Room 286, Denver, CO 80261

Retain a copy for your records.

Form Dr 1286 - Tobacco Distributor'S Certificate For Exemption Msa/non-Participating Manufacturer Brands