Form 1783 - South Dakota Tobacco Product Manufacturer Complementary Legislation Certification

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SD EForm - 1783
V13
HELP
Complete and use the button at the end to print for mailing.
SOUTH DAKOTA TOBACCO PRODUCT MANUFACTURER
COMPLEMENTARY LEGISLATION CERTIFICATION
Mail this completed Complementary Legislation Certification and attachments to:
South Dakota Department of Revenue
Mickelson Building
1302 E. Highway 14 Suite 1
Pierre, SD 57501
Please Type or Print
Part 1: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION
A.
Complete company information below:
Company Name
Address
City/State/Zip
Telephone Number
Fax Number
E-Mail Address
Website
Name/Title of Person Completing Form
Address of Manufacturing Plant(s)
Name of Factory Manager(s)
Phone Number of Factory Manager(s)
Fax Number of Factory Manager(s)
If located in the US: Manufacturer’s Federal Taxpayer ID Number:
If located in the US: TTB Tobacco Manufacturer Permit Number:
B.
The tobacco product manufacturer identified above, as of the date of this Certification, is
(check one below):
A Participating Manufacturer [Complete parts 1, 2A and 9]
A Non-participating Manufacturer [Complete entire form except 2A]
This form is (check one below):
Initial Certification – Manufacturer is not currently listed on the South Dakota Tobacco Brand Listing
Annual Certification – Due April 30, 2012
Supplemental Certification – Change of information provided to the SD Department of Revenue
All manufacturers must update this Certification thirty calendar days prior to any addition to or
modification of the Brand Families sold in South Dakota.
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