Form Otp-1 - Application For Other Tobacco Products Distributor License printable pdf download

Form Otp-1 - Application For Other Tobacco Products Distributor License

OTP-1

Rev. 7/03

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 number

Street

City

State

ZIP code

Telephone number

(

)

1. E-mail address (required):

2. Business Structure:

Sole Owner

Partnership

Corporation

Fiduciary

Association

LLC

LLP

Other

3. Type of Business:

Wholesale

Retail

Broker

Importer

4. List below the titles, names, addresses and social security numbers 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 num-

for the Tax Commissioner to administer this tax. Failure to

ber, the Federal Privacy Act of 1974 requires us to inform you

supply any information requested on a tax form prescribed

that giving us your social security number is mandatory. Our

by the Tax Commissioner may result in the denial of your

legal right to ask for this information is supported under the

license application, if applicable, or the imposition of penal-

Tax Reform Act of 1986. Your social security number is needed

ties 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 that must be renewed by February 1

of each year. Mail application and $100 application fee to the Ohio Department of Taxation, Excise Tax Unit, P.O. Box 530,

Columbus, OH 43216-0530.

Form Otp-1 - Application For Other Tobacco Products Distributor License

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