Form 5422 - Missouri Tobacco Directory - Supplemental Cigarette And Roll Your Own (Ryo) Packaging Change Notification

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MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
5422
P.O. BOX 811 JEFFERSON CITY, MO 65105-0811
MISSOURI TOBACCO DIRECTORY - SUPPLEMENTAL CIGARETTE AND
ROLL YOUR OWN (RYO) PACKAGING CHANGE NOTIFICATION
(REV. 09-2012)
PART 1: CURRENT CALENDAR YEAR
FOR OFFICE
CURRENT CALENDAR YEAR FOR
____________
20
USE ONLY
THIS NOTIFICATION:
Postmark Date:
PART 2: MANUFACTURER
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: BRAND FAMILY AND BRAND STYLE IDENTIFICATION
Check the appropriate box(es) and attach additional sheets if necessary:
Effective Date of Change(MM/DD/YYYY): ______________________
Supplemental Certification: Included is sample cigarette or RYO
Description of Change: _____________________________________
packaging (without tobacco) for each brand style listed below.
________________________________________________________
Actual packaging (without tobacco)
________________________________________________________
________________________________________________________
Electronic copy of packaging
CONTAINER
CHECK ONE
BRAND FAMILY
BRAND STYLE
SIZE
FLAVOR
CIGARETTE
RYO
CIGARETTE
RYO
CIGARETTE
RYO
CIGARETTE
RYO
CIGARETTE
RYO
CIGARETTE
RYO
CIGARETTE
RYO
PART 4: EXECUTION BY AUTHORIZED PERSON
The undersigned certifies that as of the date of this notification, the above-named company is a tobacco product manufacturer of cigarettes and/or RYO. I certify the above
information is a change to packaging only and that no changes have occurred to the brand family, brand style, ingredients, blend, tipping or paper of the actual cigarettes
and/or RYO as originally certified to the Missouri Department of Revenue and the Missouri Fire Marshal.
Under penalty of perjury, I certify and declare that all of the statements contained in this certification, including but not limited to any accompanying statements or attachments
herewith, are true, correct, accurate and complete in every particular, and that I am a person authorized to bind the tobacco product manufacturer making this notification
either under the laws of the state of Missouri or the jurisdiction where the manufacturer resides or is organized. Any violation of the requirements of sections 196.1003
and 196.1020 to 196.1035, RSMo, is basis for removal of the company’s brands from Missouri’s Directory of Compliant Tobacco Products Manufacturers.
Signature of Authorized Person:
Date(MM/DD/YYYY):
Printed Name:
Title:
Mail the original notification
Mail copies of original notification
and all supporting documents to:
and all supporting documents to:
NOTARY PUBLIC
MISSOURI ATTORNEY GENERAL
MISSOURI DEPARTMENT OF REVENUE
Taxation Division
P.O. Box 899
P.O. Box 811
207 W. High Street
301 W. High Street, Room 330
Jefferson City, MO 65102-0899
Jefferson City, MO 65105-0811
573-751-3321
573-751-7163
DOR-5422 (09-2012)
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