Form 5303 - Missouri Tobacco Directory - Non-Participating Manufacturer Brands Certification

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FORM

MISSOURI DEPARTMENT OF REVENUE

TAXATION DIVISION

5303

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

MISSOURI TOBACCO DIRECTORY - NON-PARTICIPATING MANUFACTURER BRANDS CERTIFICATION

(REV. 10-2011)

PART 1: MANUFACTURER IDENTIFICATION

COMPANY NAME

CURRENT CALENDAR YEAR

(From Form 5304 - Part 1)

PART 2: BRAND FAMILY CERTIFICATION

The undersigned manufacturer certifies, under penalties of perjury, as of the date of this certification, it is a Non-Participating Manufacturer (NPM) and is in full compliance with sections 196.1003 and

196.1020 to 196.1035, RSMo, as well as any regulations. The undersigned NPM certifies that the following list is a complete list of all its brand families which are to be deemed its cigarettes (including RYO

product) for purposes of escrow requirements under section 196.1003, RSMo.

Nothing in this certification shall limit or otherwise affect the State’s right to maintain that a brand family constitutes ciga-

rettes or RYO

of a

different tobacco product manufacturer for purposes of section 196.1003, RSMo.

Provide the following for each brand family: Brand Family, Brand Style, Size, Flavor, and Package,

as it should be listed on the Missouri Directory. Include sample packaging for each brand family named with your certification. Submit new packaging each time you change your packaging or add new brand families.

Asterisk (*) denotes those brands that will not be sold in Missouri during the current year. “Units Sold” is equal to the number of individual cigarettes sold in the state. 0.09 ounes of “roll-your-own” tobacco shall constitute one

individual cigarette.

Report Units Sold in Sticks for

Name & Address of Manufacturer of Brand

Trade Mark

Cigarettes & RYO (Convert Ounces

Fire Safe

Check

Brand Family

Brand Style

Size

Flavor

Container