Form Tmc-1 - Tobacco Manufacturer Certificate

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Indiana Department of Revenue
Tobacco Manufacturer Certificate
FORM TMC-1
SF#51483
1/04
Part 1: Tobacco Product Manufacturer Identification
Company Name
Federal FEIN or SSN
Address
TID (if applicable)
City
State
Zip Code
Country
Telephone Number
Name and Title of Person Completing Report
Fax Number
Email
The Tobacco Product Manufacturer identified above is, as of the date of this Certification:
(Initial One)
_________ A Participating Manufacturer under the Tobacco Master Settlement Agreement
_________ A Non-participating Manufacturer in full compliance with IC 24-3-3 and IC 24-3-5.4-13.
Part 2: Sales Year
Year of Sales for this Certificate of Compliance is: (complete a separate certification for each year of sales) __________________
Part 3: Brand Family Identification (Attach additional Sheets if Necessary)
Participating Manufacturers complete A & B; Non Participating Manufacturers complete A through E.
E. Manufacturer
1
1
A. Brand Family
B. Brand Name
C. Units Sold
D. Units Sold
Name & Address
Sales Year
in Current Year
(if different from above)
Part 4: Non-Participating Manufacturer Certification
A.
Registered Agent for service of process
2
Agent Name
Company
Address
City
State
Zip Code
Telephone Number
Fax Number
Email
1

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