Form 5305 - Missouri Tobacco Directory - Participating Manufacturer Certification

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FORM

MISSOURI DEPARTMENT OF REVENUE

TAXATION DIVISION

5305

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

MISSOURI TOBACCO DIRECTORY - PARTICIPATING MANUFACTURER CERTIFICATION

(REV. 10-2011)

PART 1: CURRENT CALENDAR YEAR AND TYPE OF CERTIFICATION

CURRENT CALENDAR YEAR FOR THIS CERTIFICATION:

FOR OFFICE

Complete a separate form for each liability

____________

Postmark Date:

USE ONLY

year 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:

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

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

PART 5: 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:

Is Permit/License Current?:

YES

Initial Certification or Changed Permit: A copy of current permit is attached.

Annual or Supplemental Certification: A copy of the company’s current permit was submitted with prior certification and there have been no changes

to permit.

PART 6: BRAND FAMILY AND BRAND STYLE IDENTIFICATION

Additional Information: Check the appropriate box(es):

Initial or Supplemental Certification: Included with this certification is corresponding actual cigarette or RYO packaging (without tobacco) for each brand

style for which the company requests certification.

Annual Certification - No Packaging Changes: Corresponding actual cigarette or RYO packaging (without tobacco) has been previously provided and

there have been no changes to the packaging.

Annual Certification - Packaging Changes/Brand Additions: There have been changes to the packaging samples previously submitted or new brand

styles have been added. Corresponding actual cigarette or RYO packaging (without tobacco) is included.

DOR-5305 (10-2011)