Form Ctp-121 - Certification By Non-Participating Manufacturer

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Department Use Only
State of Wisconsin
Wisconsin Department of Justice
Registration No.
PO Box 7857
CTP-121: Certification by Non-Participating Manufacturer
Madison WI 53707-7857
Phone: (608) 266-0180
New
(refer to CTP-124)
Renewal (refer to CTP-124)
(Please print or type)
I. MANUFACTURER IDENTIFICATION
Legal Name
Certification for Sales Year
Trade or Business Name
Address
Mailing Address (if different from above)
Phone
Fax
E-mail
Website
(
)
(
)
Contact Person Name
Title
Phone
A.
Domestic Manufacturer (fabricator) (Located in the U.S.)
Federal Employer Identification No. (FEIN)
WDOR Permit No. CMFR -
TMFR -
B.
Foreign Manufacturer (fabricator)
II. BUSINESS OPERATIONS
Complete all areas. If not applicable, enter “N/A”.
A.
U.S. Manufacturer (fabricator) » U.S. Federal Manufacturer Permit: TP-
-
See attached permit labeled
Exhibit
.
5210.5 federal reporting forms for prior year
»
See attached reports labeled
Exhibit
.
Products Manufactured (check all that apply)
Cigarettes
Roll-Your-Own (RYO/MYO)
Little Cigars
As Bulk Loose Tobacco
As Prepackaged Tobacco
U.S. Importer »
B.
U.S. Federal Importer Permit:
TI -
See attached permit labeled
Exhibit
.
Products Imported (check all that apply)
Cigarettes
Roll-Your-Own (RYO/MYO)
Little Cigars
As Bulk Loose Tobacco
As Prepackaged Tobacco
C.
U.S. Exporter »
U.S. Federal Exporter Permit:
EW-
-
See attached permit labeled
Exhibit
.
Products Exported (check all that apply)
Cigarettes
Roll-Your-Own (RYO/MYO)
Little Cigars
As Bulk Loose Tobacco
As Prepackaged Tobacco
D.
Manufacturer (fabricator) Outside the U.S. »
See attached government and/or local license(s)/permit(s) labeled
Exhibit
.
Products Manufactured (check all that apply)
Cigarettes
Roll-Your-Own (RYO/MYO)
Little Cigars
As Bulk Loose Tobacco
As Prepackaged Tobacco
E.
Exporter to U.S. »
Government and/or Local License(s)/Permit(s)?
Yes, see attached permit labeled
Exhibit
.
No, see explanation labeled
Exhibit
.
Products Exported to U.S. (check all that apply)
Cigarettes
Roll-Your-Own (RYO/MYO)
Little Cigars
As Bulk Loose Tobacco
As Prepackaged Tobacco
Do you export any tobacco products fabricated by another person?
Yes » See attached detailed list labeled “Exhibit
of products by brand and manufacturer (fabricator).
No
CTP-121 (R. 12-11)
Wisconsin Department of Revenue

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