Form 5304 - Missouri Tobacco Directory - Non-Participating Manufacturer Certification

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FORM

MISSOURI DEPARTMENT OF REVENUE

TAXATION DIVISION

5304

P.O. BOX 811 JEFFERSON CITY, MO 65105-0811

MISSOURI TOBACCO DIRECTORY - NON-PARTICIPATING MANUFACTURER CERTIFICATION

(REV. 10-2011)

PART 1: CURRENT YEAR AND TYPE OF CERTIFICATION

CURRENT CALENDAR YEAR FOR THIS CERTIFICATION:

FOR OFFICE

____________________

Complete a separate form for each year

Postmark Date:

USE ONLY

for which you are certifying (check one)

TYPE OF CERTIFICATION (check one):

Initial

Annual

Supplemental

PART 2: MANUFACTURER IDENTIFICATION

Company Name:

Federal I.D. Number:

__ __ __ __ __ __ __ __ __

Mailing Address:

City:

State:

Zip Code:

Country:

__ __ __ __ __

Physical Address:

City:

State:

Zip Code:

Country:

__ __ __ __ __

Telephone Number:

Fax Number:

E-mail Address:

__ __ __ __ __ __ __ __ __ __ __ __ __ __

PART 3: CONTACT PERSON

Missouri Statute 32.057, RSMo, states that all tax records and information maintained by the Missouri Department of Revenue are confidential. The tax information can only be given to the

owner, partner, member, or officer who is listed with us as such. If you wish to give an employee, attorney, or accountant access to your tax information, you must supply us with a power of

attorney giving us the authority to release confidential information to them.

Contact Person For Certification

Telephone Number:

__ __ __ __ __ __ __ __ __ __ __ __ __ __

Power of Attorney:

E-Mail Address:

YES*

*If Yes, attach a completed Form 2827 for Power of Attorney

PART 4: MANUFACTURING FACILITY INFORMATION

Plant Name:

Physical Address:

City:

State:

Zip Code:

Country:

__ __ __ __ __

Plant Telephone Number

Plant Fax Number:

__ __ __ __ __ __ __ __ __ __ __ __ __ __

Name/Title of Contact Person at Plant (if different than above):

PART 5: STATUS AS A TOBACCO PRODUCTS MANUFACTURER

The undersigned certifies that as of the date of this Certification, the above-named company is a Non-Participating Tobacco Products Manufacturer in full compliance with

196.1000 to 196.1003, RSMo, including having made all required payments into a Qualified Escrow Fund as defined in 196.1000(f), RSMo. The company qualifies as a

Non-Participating Tobacco Product Manufacturer because (check all that apply):

The company is the fabricator of the listed brands in this Certification which are intended to be sold in the United States including cigarettes and RYO

intended to be sold in the United States through an importer.

The company is the first purchaser anywhere for resale in the United States of cigarettes and RYO manufactured anywhere that the manufacturer does not

intend to be sold in the United States. If yes, provide the name, plant address, contact person, phone and fax number of the fabricator.

The company is a successor of any entity described above (i.e. manufacturer/first importer). If yes, provide the name, plant address, contact person,

telephone number and fax number for the entity this company is succeeding.

PART 6: LICENSE AND PERMITS

U.S. Treasury, Tobacco Tax Bureau (TTB) Permit Number:

Country Issued:

Last Year Permit or License Issued:

Is Permit/License Current?:

YES

Foreign Manufacturer Permit Number (if applicable):

Country Issued:

Last Year Permit or License Issued: