Form Dr 0222 - Tobacco Products Distributor Application

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Department Use Only
DR 0222 (02/07/12)
COLORADO DEPARTMENT OF REVENUE
EXCISE TAX ACCOUNTING SECTION -
ROOM 237
Tobacco Products
DENVER CO 80261-0009
Distributor Application
303- 205-8211 ext. 6879
This form is to be used by new distributors or change of ownership.
A separate license is required for each place of business.
A license will not be issued if the taxpayer owes any delinquent taxes administered by
the department.
For forms go to
Type of Ownership
Account Number
INDIVIDUAL
GENERAL PARTNERSHIP
OTHER (specify):
______________________________
CORPORATION
LLC
Taxpayer Name (owner, partners or corporation) (last, first, middle)
Trade Name/Doing Business As (if applicable)
Address of Principal Place of Business (street)
City
ZIP
State
Telephone
Email Address (required)
(
)
Mailing Address (if different from above)
City
ZIP
State
Telephone
FEIN/SSN (required)
First Day of Business
Period
(Dept. use only)
(
)
A tobacco products license is required if the applicant qualifies in any of the following categories. Check the appropriate boxes:
Check all that apply
Tobacco Products Distributor —
First to receive tobacco products in the state.
Ships or transports tobacco products to retailers in Colorado.
Purchase tobacco products from manufacturer or unlicensed out-of state wholesaler.
A person, firm, limited liability company, partnership or corporation who purchases excise tax paid
Tobacco Products Distributing Subcontractor —
tobacco products from a licensed Colorado tobacco products distributor for resale to a retailer in the state.
The following must accompany this application before your license can be issued:
3 My sales tax Department of Revenue account number is
.
If you do not have a valid Department of Revenue sales tax account number, enclose a completed CR 0100, Colorado Sales Tax/Wage
Withholding Account Application, and the proper license fee with this application.
3 Form DR 1286 and/or DR 1285.
3 A completed DR 5785, Authorization for Electronic Funds Transfer (EFT) For Tax Payments. (not required for Tobacco Products
Distributing Subcontractors)
The license fee is based on a fiscal year beginning July 1 and ending June 30. If opening date of the business occurs:
FEE SCHEDULE
JULY
OCTOBER
JANUARY
APRIL
0222-750
AUGUST
NOVEMBER
FEBRUARY
MAY
SEPTEMBER
DECEMBER
MARCH
JUNE
Tobacco Products
•1
License Fee..............
$
FEE: $10.00
FEE: $7.50
FEE: $5.00
FEE: $2.50
The State may convert your check to a one time electronic banking transaction. Your bank account may be debited as early as the same day received by the State. If converted, your check will
not be returned. If your check is rejected due to insufficient or uncollected funds, the Department of Revenue may collect the payment amount directly from your bank account electronically.
The applicant agrees that upon acceptance of the license granted by the Department for tobacco products tax, that they are subject
to all provisions of the following statutes and regulations: § C.R.S., Title 39, Article 28.5 Tobacco Products, Title 39, Article 28, Part 2-
Tobacco Escrow Funds, Title 39, Article 28, Part 3-Additional requirements for tobacco product manufacturers and stamping agents.
The Certified Brands Directory, FYI’s, regulations and statutes are available at . Non-compliance with these
statutes and regulations can result in revocation of the license(s) for two years.
I declare under penalty of perjury in the second degree that the statements made in this application are true and complete to the best of my knowledge.
(Signature required below.)
Type or Print Authorized Signature
Title
Signature of Owner, Partner or Corporate Officer
Date

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