Form Ct100 - License Application For Cigarette Distributors And Subjobbers - 2012 Page 2
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2Form CT100 page 2
Distributors
List the name and address of each manufacturer from whom you purchase or intend to purchase cigarettes.
Enter the date of your first untaxed cigarette purchase:
Subjobbers
List the name and address of each Minnesota licensed distributor from whom you purchase or intend to purchase cigarettes.
Subjobbers cannot purchase untaxed cigarettes or other tobacco products.
All applicants
Check license applied for:
New application
Renewal
Two-year licensing period 2012-13
Application made after Jan. 1, 2013
Fee
Fee
Cigarette distributor
$300 .00
Cigarette distributor
$150 .00
Cigarette subjobber
$24 .00
Cigarette subjobber
$12 .00
Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we must advise you of the following:
• This information may be used to deny the issuance or renewal of your license if you owe the Minnesota Department of Revenue
delinquent taxes, penalties or interest.
• Under the Federal Exchange of Information Act, the Department of Revenue is allowed to supply this information to the Internal
Revenue Service.
• Failing to supply this information may jeopardize or delay the issuance of your license or processing of your renewal application.
I acknowledge that by becoming licensed as a cigarette distributor or subjobber, I will have record keeping/reporting requirements
and responsibilities. I agree to comply with the applicable tax statutes as a condition of my license, and declare that the information
given in this application is true, correct and complete to the best of my knowledge and belief.
Authorized signature
Title
Date
Daytime phone
Mail to: Minnesota Revenue, Mail Station 3331, St. Paul, MN 55146-3331.
Phone: 651-556-3035 (TTY: Call 711 for Minnesota Relay). Email: cigarette.tobacco@state.mn.us
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