Form 5300 - Non-Participating Manufacturer'S (Npm) Appointment Of Registered Agent For The State Of Missouri

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MISSOURI DEPARTMENT OF REVENUE

FORM

TAXATION DIVISION

P.O. BOX 811

5300

JEFFERSON CITY, MO 65105-0811

NON-PARTICIPATING MANUFACTURER’S (NPM) APPOINTMENT OF

(REV. 10-2011)

REGISTERED AGENT FOR THE STATE OF MISSOURI

PLEASE PRINT OR TYPE IN PERMANENT DARK INK

SIGN, DATE AND RETURN ORIGINAL TO:

PLEASE SEND A COPY OF THE ORIGINAL FORM TO:

Missouri Department of Revenue

Missouri Attorney General

Taxation Division

PO Box 899

PO Box 811

207 W High

Jefferson City MO 65105-0811

Jefferson City MO 65102-0899

NON-PARTICIPATING TOBACCO MANUFACTURERS

The undersigned Non-Participating Manufacturer (NPM) _______________________________________________________________

hereby appoints and authorizes __________________________________________________________________________________

as its registered agent to receive service of process on our behalf. The undersigned NPM agrees to provide notice to the Director of

Revenue, at least 30 (thirty) days prior to termination of the authority of the registered agent, and to provide proof to the satisfaction of

the Director of Revenue of the appointment of a new agent at least five calendar days prior to the termination of an existing agent

agreement.

Under penalty of perjury, I certify and declare that all of the statements and information contained in this Certification, including but not

limited to any accompanying statements or attachments herewith, are true, accurate and complete in every particular and that I am a

person authorized to bind the NPM making the Certification either under the laws of the state of Missouri or of the jurisdiction where

the manufacturer resides or is organized. Any violation of the requirements of section 196.1026, RSMo, is a basis for removal of the

applicant’s brand families from Missouri’s Directory of Compliant Tobacco Products Manufacturers. Brand families that are not listed on

Missouri’s Directory of Compliant Tobacco Products Manufacturers are not eligible to be sold in the state of Missouri.

UNDER PENALTY OF PERJURY, I STATE THAT THE INFORMATION CONTAINED IN THIS DOCUMENT IS TRUE AND ACCURATE.

SIGNATURE OF AUTHORIZED PERSON FOR NON-PARTICIPATING MANUFACTURER

DATE SIGNED

__ __ / __ __ / __ __ __ __

AUTHORIZED PERSON - PRINTED NAME

TITLE

PRINCIPAL PLACE OF BUSINESS (PHYSICAL ADDRESS)

If you have questions or need assistance in completing this form, please call (573)751-7163 or e-mail excise@dor.mo.gov. You may also obtain this form from the

Department’s web site at: , or TDD (800)735-2966.

DOR-5300 (10-2011)