Form 2175 - Missouri Cigarette/other Tobacco Products Tax License Application Page 5

Download a blank fillable Form 2175 - Missouri Cigarette/other Tobacco Products Tax License Application in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 2175 - Missouri Cigarette/other Tobacco Products Tax License Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

FORM 2175 MISSOURI CIGARETTE/OTHER TOBACCO PRODUCTS

TAX LICENSE APPLICATION

DO NOT WRITE IN THE BLOCK LABELED “FOR OFFICE USE ONLY”. THIS IS FOR DEPARTMENT USE ONLY.

Type of Application

Check the appropriate box indicating whether the application being submitted is a new license or renewal. Check the application box indicating which type of license you are

registering.

Missouri Tax Identification Number

Enter the eight digit Missouri Tax Identification Number issued to your company in the space provided, otherwise leave blank.

Federal Employer Identification Number

Enter the Federal Employer Identification Number issued to your company by the Federal Government, otherwise leave blank.

Section 1: Business Name and Location

Enter your business name, DBA name, web site address, physical location of business, mailing address, address where books and records are kept, county, telephone

number and fax number.

Section 2 - Type of Ownership

Check the box that describes the ownership structure of your business.

If your company is not in compliance with the Missouri Secretary of State’s Office, you will need to contact them in order to determine if you need to be registered. You may

reach them by telephone at (573) 751-3827 or visit the web site at If your company does not meet the requirements to registered, please submit a

letter along with your application stating the reason for exemption.

SECTION 3 - Contact Persons

Provide the requested information for contact persons for registration, other tobacco, cigarette, and MSA reports, along with a telephone number and e-mail address for each

individual.

If a person(s) other than an owner or officer of the company is listed as a contract for any of the above categories, please check the box for Power of Attorney and attach a

completed Form 2827 giving the listed person(s) the Power of Attorney for your company.

Missouri Statute 32.057, RSMo, states that all tax records and information maintained by the Missouri Department of Revenue are confidential. The tax information

can only be given to the owner, partner, member, or officer who is listed with us as such. If you wish to give an employee, attorney, or accountant access to your tax

information, you must supply us with a Power of Attorney giving us the authority to release confidential information to them.

Section 4 - Ownership Information

Provide the requested information for the owners, officers, partners or members of the business.

Section 5 - Previous Owner Information

Provide the requested information for any previous owners, officers, partners or members of the business. This section is only applicable if you purchased an existing

business.

Section 6 - Names of any Persons Associated with your Company who presently or Previously Owned, Operated or Managed Another Cigarette or Tobacco

Company

Provide the requested information for any individuals associated with your company who meet the requirements outlined above.

Section 7 - Business Activities

Check all applicable boxes as they apply to your business.

Check the appropriate box if you purchase all products directly from the manufacturer. Provide the name, address, and telephone number of each manufacturer.

Check the appropriate box if you purchase products from Missouri licensed wholesalers. Provide the name and license number of each wholesaler and check box to

indicate whether you are going to purchase product tax paid or tax unpaid.

Check the appropriate box if you purchase other tobacco products from suppliers that are not Missouri licensed wholesalers. Provide the name, address, and telephone

number of each supplier.

Check the appropriate box if you operate retail stores where cigarette and tobacco products are sold. Provide the physical address and Missouri Tax Identification Number

for each location.

Check the appropriate box if you own, operate, or service cigarette vending machines or humidors. Provide the retail store name, address, and Missouri Tax Identification

Number for each location.

Check the appropriate box if you place other tobacco products on consignment in retail locations. Provide the retail store name and complete address of each location, as

well as submission of a copy of the contract between yourself and the retailer.

Check the appropriate boxes indicating whether you buy and/or sell tobacco products on the Internet, by telephone, or by catalog sales.

Section 8 - Cigarette Tax Stamping Information

Check the appropriate box indicating which method will be used to affix cigarette tax stamps.

Section 9 - Cigarette Tax Stamp Purchasing Information

Check the appropriate box indicating your shipping method for cigarette tax stamps. Also indicate which method will be used to purchase cigarette tax stamps.

Section 10 - Bond Information

Check the appropriate box indicating which type of bond you are submitting for each applicable activity type.

Persons applying for both a cigarette and other tobacco products license must submit a separate bond type for each license type.

Persons applying for an other tobacco products license must post a minimum $500 bond to meet the initial bonding requirement. The Director may request a bond increase

up to the maximum amount.

Section 11 - Reporting Forms

Indicate whether you are licensed for cigarette or other tobacco products in other states. List the states and corresponding license numbers.

Check the appropriate box to indicate by which method you would like to receive forms and updates.

Check the appropriate box to indicate whether the required Registration for Electronic Notification of Changes in the Missouri Tobacco Directory is attached.

Check the appropriate box to indicate submission of the Missouri Secretary of State Certificate of Organization. This document is not required if your business is structured

as a sole proprietorship.

Section 12 - Signature

Provide the requested information. The person signing the application must be listed in Section 4 or there must be a Power of Attorney Form 2827 attached for the person

signing.

DOR-2175 (08-2012)