Form 55b - Tobacco Product Manufacturer'S Certification - 2017 Page 6
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10Part 4: Nonparticipating Manufacturer
A. Identification of Directors, Members, Officers, and Owners of the Company:
Interested Party
Nature of Interest
Address
Phone and Fax Numbers
B. Association With Other Tobacco Product Manufacturers
Are any of the individuals or entities identified in Part 4A also directors, members, officers, or owners
of any other tobacco product manufacturers?
Yes
c
No
c
If yes, please explain:
C. Federal Excise Tax Paid
The nonparticipating manufacturer identified in Part 1, must provide the following information:
1.
Total nationwide sales on which federal excise tax was paid in the preceding calendar year __________.
Note: If the manufacturer identified in Part 1 is a domestic tobacco product manufacturer, a copy of the Tobacco
Tax Bureau Form 5210.5 supporting the total sales number must be attached to this Certification.
If the manufacturer identified in Part 1 is a foreign tobacco product manufacturer, a copy of Tobacco Tax Bureau
Form 5220.6 supporting the total sales number must be attached to this Certification.
2. Total nationwide sales reported pursuant to 15 U.S.C. § 376 during the preceding calendar year __________.
Note: Copies of all reports made pursuant to 15 U.S.C. § 376, including reports to states other than Nebraska, shall be
made available to the Nebraska Department of Revenue or Nebraska Attorney General’s Office upon request.
Part 5: Nonparticipating Manufacturer Stamping Agent
Provide the following information for all stamping agents to whom cigarettes and/or roll-your-own tobacco were sold by, or
on behalf of, the nonparticipating manufacturer identified in Part 1 for distribution in Nebraska in the current or preceding
year (attach additional sheets if necessary).
Phone
Number
Name of Stamping Agent
Address
Brand
Note: Stamping Agent is defined in § 69-2706(20) as a person authorized to affix stamps to packages of cigarettes or a
person required to pay the tobacco products tax imposed on roll-your-own tobacco. The nonparticipating manufacturer
shall update this information if it changes during the calendar year.
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