Form Cg-80 - Application For Registration As A Chain Store (Page 4 of 4) in pdf

Page 4 of 4 CG-80 (11/04)

19. List all current or anticipated cigarette suppliers. Attach additional sheets if necessary.

Name of supplier

Address of supplier

Street

City

State

ZIP Code

Street

City

State

ZIP Code

Street

City

State

ZIP Code

20. If you are applying as a cooperative member, did you purchase from the cooperative in the preceding

3 months at least 25% of all merchandise purchased for resale (excluding cigarettes and petroleum

products)? The calculation of the percentage is based on price paid ........................................................................

Yes

21. If you are applying as a cooperative member, do you share in the profits and losses of the cooperative? ...................

Yes

22. If you are applying as a large volume outlet operator, did one or more of your retail outlets

through which cigarettes are sold in New York State have gross sales (excluding petroleum

products) of more than $2,000,000 in the preceding calendar year? .........................................................................

Yes

Note: This application for registration as a chain store will not be approved until all of the following conditions are met:

— You are registered as a sales tax vendor. Include a copy of the sales tax Certificate of Authority for each outlet. If you are not so

registered, submit Form DTF-17, Application for Registration as a Sales Tax Vendor (see Need help? on Form CG-80-

— You and all persons listed in item 12 have satisfied all outstanding tax liabilities and have filed all appropriate tax returns.

— You have submitted the required documentation for the type of business under which you are registering as a chain store (see

instructions) .

— You have registered each location and each vending machine. If not, submit Form DTF-716, Application for Registration of Retail

Dealers and Vending Machines for Sales of Cigarettes and Tobacco Products.

— You are licensed as a wholesale dealer if you own, operate, or maintain one or more cigarette vending machines in, at, or upon

premises owned or occupied by another person. If you are not licensed as a wholesaler dealer but should be, submit

Form CG-100-V, Application for License as a Wholesale Cigarette Dealer Who Only Operates Vending Machines .

— The application is signed and dated by an officer, director, shareholder, partner, or the sole proprietor listed in item 12 of this

application.

— A bank check, certified check, money order, or other draft acceptable to the department for the applicable registration fee, made

payable to, Commissioner of Taxation and Finance , is submitted with the application. Mail all documents to:

NYS TAX DEPARTMENT

TTTB FACCTS - REGISTRATION AND BONDING UNIT

BUILDING 8

W A HARRIMAN CAMPUS

ALBANY NY 12227

Warning

The Department of Taxation and Finance has the right to suspend or revoke a registration as a chain store for violation of the provisions of

Tax Law Article 20 (Cigarette Tax Law) or Tax Law Article 20-A (Cigarette Marketing Standards Act).

It is a Class B misdemeanor for a chain store to induce or attempt to induce, or to procure or attempt to procure, the purchase of

cigarettes at a price less than the cost of the agent or wholesaler with respect to sales to chain stores.

It is also a Class B misdemeanor for a chain store to induce or attempt to induce, or to procure or attempt to procure, any rebate or

concession of any kind in connection with the purchase of cigarettes.

Making a false or misleading statement on this application will be viewed by the department as an attempt to procure cigarettes below the

minimum price and will result in the revocation or your registration as a chain store. In addition, the department may forbid you from

subsequently selling cigarettes at retail.

I certify that the information herein provided is true and correct to the best of my knowledge, and that the

Certification —

applicant herein named is qualified under the Cigarette Marketing Standards Act to be a chain store.

Name

Title

(print)

Signature

Date

Form Cg-80 - Application For Registration As A Chain Store Page 4

Related Articles

Related forms

Related Categories