Form 70-014 - Application For Iowa Retail Cigarette / Tobacco Permit Page 2
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1
2Instructions for Iowa Retail Cigarette / Tobacco Permit Application
(MUST BE PRINTED CLEARLY OR TYPED)
Cigarettes must be sold at the minimum price set by the State of Iowa. Obtain a current copy
of the minimum price list from the Iowa Department of Revenue Web site at
(click on Forms, select Cigarette/Tobacco, select Forms).
__________________________________________________________
ONLY APPROVED BRANDS OF CIGARETTES OR ROLL-YOUR-OWN PRODUCTS MAY BE SOLD IN IOWA
Any brand not on the list is contraband. In
The list of approved brands is always current at
addition, all cigarettes sold in Iowa must have
an Iowa Cigarette Tax Stamp affixed to each
and is called
package. Any violation of contraband or non-
Iowa cigarette tax stamped package is subject
IOWA DIRECTORY OF CERTIFIED TOBACCO
to seizure and penalties under the provisions of
PRODUCTS MANUFACTURERS —
THEIR BRANDS AND BRAND FAMILIES
Iowa Code 453A and 453D.
A new application must be submitted every year.
All retailers need to sign up for the Cigarette/
A permit will not be issued until the application is
Tobacco eList (listserv).
properly completed.
You will receive an e-mail every time the
approved list changes or the minimum price list
Fill in the month, day and year that this application
changes.
covers.
Go to
All permits expire June 30th. Normally this period will
be the Fiscal Year July 1st through June 30th.
BUSINESS INFORMATION
Fill in the name the business is known by - DBA (doing business as).
Fill in the REQUIRED location and mailing address, city, and zip where the business is actually located;
that is, the 911 address. Add the post office box if required for mail delivery.
Check whether the cigarettes will be sold through a vending machine or over the counter.
Fill in the 10-digit telephone number of the business.
Check one type of retail establishment; that is, bar, convenience store-no gas, convenience-with gas, drug, gas
station, grocery, hotel/motel, liquor store, restaurant, tobacco store, other. If “other,” please write in type.
LEGAL OWNER INFORMATION
Check whether the legal ownership of the business is individual, a partnership, a corporation, a Limited
Liability Corporation (LLC), or a Limited Liability Partnership (LLP).
Fill in the name of the individual, the partnership, the corporation, the LLC, or the LLP that is the legal owner
of the business. This is NOT the store manager or corporate president.
Fill in the mailing address, post office box (if required for mail delivery), city, state, zip and telephone
number of the above named legal owner.
Fill in the fax number and e-mail address of the legal owner.
Print the name of the individual owner, partner(s) or corporate official signing this application.
Sign and date the application. The application must be signed by the owner, one of the partners, or one of the
corporate officers listed above. A preparer’s or store manager’s signature is not acceptable unless he or she is
one of the owners, partners, or corporate officers.
Return this application to your local jurisdiction: city clerk (within city limits)
or county auditor (outside city limits).
70-014b (05/30/12)
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Parent category: Financial