Form Tt-1 - Virginia Application For Cigarette Stamping Permit And Tobacco Products Tax Distributor'S License

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Form TT-1
For Off ce Use Only
Commonwealth Of Virginia
Virginia Department Of Taxation
Application for Cigarette Stamping Permit And
Tobacco Products Tax Distributor’s License
•
Please read instructions before completing application.
•
A Schedule A must be completed for any officer, director, manager, sole proprietor, partner, member, stockholder, or any other person possessing an
ownership interest of 10% or greater in the applicant, who exercises authority or control over the purchase, storage, sale or distribution of cigarettes or
other tobacco products (“OTP”), or over the compliance with any cigarette or tobacco products tax laws.
•
A completed Schedule A must also be f led within 10 days for any person meeting this criteria after the date of this application.
•
A non-refundable fee of $600 is required with the application. Make the check payable to the Department of Taxation.
•
Please print or type.
New License
Renewal - Current Permit/License Number
Type of Application
Cigarette Stamping Agent Permit
Tobacco Product (OTP) Tax Distributor’s License
Applying For (Check all that apply.)
If applying for an OTP Taxes Distributor’s License, do you make purchases of untaxed Roll-Your-Own Cigarette Tobacco? (check one)
Yes
No
If applying for an OTP Taxes Distributor’s License, you are a (check one)
Retailer
Wholesaler
Chain Store
A. Business Name and Street Address (No Post Offi ce Boxes) - See Instructions
OTP Distributor’s License
Item
Cigarette Stamping Agent Permit
(OTP records must be stored at this address.)
Legal Business Name
Trading as Name, If
Different
FEIN/SSN
Date Business Opened
Physical Address
City, State, ZIP
Telephone Number
(
)
(
)
Fax Number
(
)
(
)
Company Web-site
Address
E-mail Address
B. Type of Ownership
Sole Proprietor
Partnership
LLC
C Corp.
S Corp.
Other
C. If Other Than A Sole Proprietor, Provide The Following
President’s Name
Chief Financial Off cer’s Name
D. Business Mailing Address
Business Mailing Address (PO Box or Number and Street Name)
City
State
ZIP
E. Cigarette Stamping Record Storage Address (No Post Offi ce Boxes) - If different than above.
Record Storage Address (Number and Street Name)
City
State
ZIP
F. Person to Contact Regarding Application
Name (Printed)
Title
Telephone Number
E-mail Address
G. If a Stamping Agent, List Virginia Localities for Which You Purchase and Affi x Cigarette Tax Stamps - Attach list if necessary.
Va. Dept. of Taxation
TT-1 W
6201079
REV 01/13
Page 1

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