Form 5298 - Registration For Electronic Notification Of Changes In The Missouri Tobacco Directory

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MISSOURI DEPARTMENT OF REVENUE
TAXATION DIVISION
FORM
P.O. BOX 811
5298
JEFFERSON CITY, MO 65105-0811
REGISTRATION FOR ELECTRONIC NOTIFICATION OF
(REV. 07-2010)
CHANGES IN THE MISSOURI TOBACCO DIRECTORY
Section 196.1023.2(3), RSMo, requires every stamping agent (wholesaler) to maintain and provide to the Director of Revenue an
electronic mail address for the purpose of receiving notices concerning Missouri’s tobacco directory.
PLEASE PRINT OR TYPE:
MISSOURI CIGARETTE OR OTHER TOBACCO PRODUCTS (OTP)
FEDERAL I.D. NUMBER
LICENSE NUMBER
__ __ __ __ __ __ __ __ __
COMPANY NAME
PHYSICAL ADDRESS
MAILING ADDRESS ( IF DIFFERENT FROM ABOVE)
TELEPHONE NUMBER
FAX NUMBER
( __ __ __ ) __ __ __ - __ __ __ __
( __ __ __ ) __ __ __ - __ __ __ __
TITLE
CONTACT PERSON
E-MAIL ADDRESS
WEB SITE ADDRESS
THE COMPANY LISTED ABOVE IS A
CIGARETTE OR OTP WHOLESALER
OTP RETAILER
OWNER OR OFFICER SIGNATURE
PRINT NAME
TITLE
DATE
__ __ / __ __ / __ __ __ __
NOTE: IF YOUR E-MAIL ADDRESS CHANGES, YOU MUST FILE A NEW FORM.
MAIL COMPLETED FORM TO: Taxation Division, Excise Tax, P.O. Box 811, Jefferson City, MO, 65105-0811. If you
have questions or need assistance in completing this form, please call (573) 751-7163 / TDD (573)735-2966; or e-mail
excise@dor.mo.gov. You may also obtain this form from the Department’s web site at
This form is available in alternate accessible format(s).
DOR-5298 (07-2010)

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