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Form Cg-100-V - Application For License As A Wholesale Cigarette Dealer Who Only Operates Vending Machines Page 6

Page 6 of 8 CG-100-V (1/02)

14. Does the applicant or any person required to be listed in item 4 or 5 have a liability for any tax imposed by or pursuant to the authority

of the NYS Tax Law, or for the City of New York or for the City of Yonkers earnings tax on nonresidents, that has been finally determined

Yes

to be due and has not been paid in full?

(complete below)

Person’s name

Type of tax

Amount due

Assessment number

Assessment date

15. List all bank accounts of the applicant:

Bank name

Address

Account number

Type

16. In columns A through C, enter the business name and address where each of your vending machines is located and its manufacturer

and machine serial number. If you have several machines at one location, enter the address only once, but list the manufacturer and

machine serial number of every machine at the location. Also include all machines not in use and list where stored. You must indicate

the total number of machines in use, the total number of machines not in use, and the grand total of all machines in the spaces

provided. The grand total must agree with the total of all machines shown here and on any additional sheets being attached.

Business name

Address where vending machine is located

Manufacturer and

(report each machine separately)

machine serial number

(continued on next page)

Attach additional sheets as needed. Please include the item number referenced on additional sheets.

Form Cg-100-V - Application For License As A Wholesale Cigarette Dealer Who Only Operates Vending Machines Page 6