Form Rc-25-A - Cigarette Manufacturer/importer Certification
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Illinois Department of Revenue
REV 01 FORM 908
RC-25-A Cigarette Manufacturer/Importer Certification
Step 1: Identify yourself
1
3
Business name ____________________________________________________
License no.: ___ - ___ ___ ___ ___ ___
4
Address __________________________________________________________
Check your business type:
Number and street
_________________________________________________________________
manufacturer
importer
City
State
Country
ZIP
2
Check here if all the cigarettes you import into the United States comply with the requirements in the perjury statement listed in Step 2:
Step 2: Sign below
Under penalties of perjury, I state that the above business has complied with the package health warning and ingredient
reporting requirements of the federal Cigarette Labeling and Advertising Act, 15 U.S.C. 1333 and 1335a; and the provisions of
Exhibit T of the Master Settlement Agreement entered in the case of People of the State of Illinois v. Philip Morris, et al. I also
state that the above business is (check one):
a participating tobacco manufacturer within the meaning of Exhibit T.
not a participating tobacco manufacturer within the meaning of Exhibit T.
__________________________________________________ _________________________________________________
Authorized officer signature
Printed name of the person who signed this certification
_________________________
(_____)_____ - _____________
___ ___/___ ___/___ ___ ___ ___
Title of the person signing above
Month
Day
Year
Telephone number
Reset
Print
*390811110*
Note:
Do not send any payment with this certification.
This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is filed. Disclosure of this
information is required. Failure to provide information may result in this form not being processed and may result in a penalty.
RC-25-A (R-07/13)
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