Form Ctl - Application For All Cigarette Licenses - Except Retailer'S License - 2013-2014 Page 2

Download a blank fillable Form Ctl - Application For All Cigarette Licenses - Except Retailer'S License - 2013-2014 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Ctl - Application For All Cigarette Licenses - Except Retailer'S License - 2013-2014 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Reason for application.

Check one:

Started new business

Renewal

Purchased existing business

Provide application information:

Name of previous owner

License number

Street address

City/Town

State

Zip

Organizational change. Provide applicable information:

Name of previous organization

License number

Street address

City/Town

State

Zip

Provide name and address of all licensed parties other than the licensed retailers who purchase cigarettes from you. Attach additional list, if necessary.

Name

Street address

City/Town

State

Zip

Name

Street address

City/Town

State

Zip

Miscellaneous

Provide information on licensed cigarette wholesaler(s) and/or manufacturer(s) from whom you will purchase cigarettes. Attach additional sheet, if necessary:

Name

Street address

City/Town

State

Zip

Name

Street address

City/Town

State

Zip

Name

Street address

City/Town

State

Zip

Are any Massachusetts tax returns due or any Massachusetts taxes owed by your firm?

Yes (attach statement)

Has your cigarette license ever been revoked?

Yes (attach statement)

Quantity of retailers served:

Are cigarettes sold at retail and wholesale at same location?

Yes

Cigarette stampers only

Effective September 1, 2003 all purchases of cigarette stamps must be paid via electronic funds transfer. If you wish to pay with 30-day credit you must have

on file a surety bond (Form Excises 2) and/or bonds or other negotiable obligations of the Commonwealth of Massachusetts or of the federal government.

Amount of credit applied for:

To all licensees

If for any reason you cease to sell cigarettes during the license period, return your license so that DOR can maintain an accurate and current license file.

Mark the license “Cancelled” with the date of cancellation.

It is your responsibility as a licensed retailer to abide by the provisions of Massachusetts General Laws, including Chapters 62C and 64C. Failure to adhere

to these statutes may jeopardize your license. Of specific importance are the sections in Chapter 64C (sec. 12–21) that deal with cigarette minimum pricing.

I hereby certify that the statements made herein have been examined by me and are, to the best of my knowledge and belief, true and correct

and I agree to conform with the provisions of the Massachusetts General Laws, Ch. 62C and Ch. 64C, as amended, and with all rules and regula-

tions made thereunder, and have complied with all laws of the Commonwealth relating to taxes. Signed under the pains and penalties of perjury.

Signature of authorized officer

Title

Date

The signing of this application is evidence that you may be individually and personally responsible for any sums required to be paid to the Commonwealth,

under MGL, Chapter 64C. Make check payable to Commonwealth of Massachusetts. Mail to: Massachusetts Department of Revenue, Cigarette Excise

Unit, PO Box 7004, Boston, MA 02204.

printed on recycled paper