Form 5301 - Missouri Tobacco Directory - Participating Manufacturer Brands Certification

Download a blank fillable Form 5301 - Missouri Tobacco Directory - Participating Manufacturer Brands Certification in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 5301 - Missouri Tobacco Directory - Participating Manufacturer Brands Certification with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Reset Form

Print Form

Missouri Department of Revenue

Form

Taxation Division

5301

P.O. BOX 811 Jefferson City MO 65105-0811

MISSOURI TOBACCO DIRECTORY - PARTICIPATING MANUFACTURER BRANDS CERTIFICATION

(REV. 10-2011)

PART 1: MANUFACTURER IDENTIFICATION

COMPANY NAME

PART 2: BRAND FAMILY CERTIFICATION

As of the date of this certification, the manufacturer identified in Part 2 of Form 5305 is a Participating Manufacturer (PM) and has generally performed its

financial obligations under the Master Settlement Agreement(MSA). The PM certifies that the brand families listed in this certification are a complete list of

the brand families which are deemed to be its cigarettes (including RYO product) for purposes of calculating payments under the MSA in the volumes and

shares determined pursuant to the MSA. Nothing in this certification shall limit or otherwise affect the State’s right to maintain that a brand family constitutes

cigarettes or RYO tobacco of a different tobacco product manufacturer for the purposes of calculating payment under the MSA.

Asterisk (*) denotes brands that will not be sold in Missouri during the current year.

PACKAGING

FIRE SAFE

SIZE

SUBMITTED

BRAND FAMILY

BRAND STYLE

CONTAINER

FLAVOR

CHECK ONE

(Y/N)