Form BOE-400-LMR Fillable Annual Certification for Manufacturer's/Importer's License

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Download Form BOE-400-LMR

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($5 000) or both the imprisonment and the fine (1 BUSINESS OR TRADE NAME (DBA if any)) (2 BUSINESS ADDRESS (do not list PO Box or mailing service)) (3 MAILING ADDRESS (if different from No 2 above)) (4 NAME OF BOOKKEEPER/ACCOUNTANT) (5 NAME OF REGISTERED AGENT FOR RECEIPT OF SERVICE OF PROCESS IN THIS STATE) (ADDRESS) (BOE USE ONLY) (BOE USE ONLY) (BOE USE ONLY) (BOE USE ONLY) (BUSINESS TELEPHONE NUMBER (area code)) (BUSINESS TELEPHONE NUMBER) (City of) (CITY) (CLEAR) CLEAR (COMMISSION EXPIRES) (continued on reverse) (Date business discontinued) (DATE) (DATE) (Daytime telephone number) (EMAIL ADDRESS) (EMAIL ADDRESS) (FOID) (FROM) (I changed the ownership of my business on) (Mailing address) (Mailing address) (NAME (typed or printed)) (PRINT NAME AND TITLE) (PRINT) PRINT (S1F) Section I: Cigarette License Account Information; page (S1B) which includes Section II: Cancellation (S2) which consists of Section VI: Requirement to Update Schedule of Cigarette Brand Family Names; Section (STATE) (Subscribed and sworn to before me on this date) (TELEPHONE (AREA CODE)) (TELEPHONE NUMBER ( AREA CODE)) (TELEPHONE NUMBER (AREA CODE )) (TELEPHONE NUMBER (AREA CODE)) (TELEPHONE NUMBER) (TELEPHONE) (text) (TITLE) (YOUR ACCOUNT NO ) (ZIP CODE) [ FOID 1 BUSINESS OR TRADE NAME (DBA if any) 2 BUSINESS ADDRESS (do not list PO Box or mailing service) STATE 3 MAILING ADDRESS (if different from No 2 above) CITY STATE ZIP CODE 4 NAME OF BOOKKEEPER/ACCOUNTANT 5 NAME OF REGISTERED AGENT FOR RECEIPT OF SERVICE OF PROCESS IN THIS STATE 942879 Sacramento CA 94279 0088 You may also visit the BOE website at www boe ca gov or call the Taxpayer A change in the ownership type of your business requires a new license to be issued You can apply for accounts a copy to the BOE whenever a new or additional brand is manufactured or imported by the a witness ADDRESS and Professions Code (the Act) The Act requires every manufacturer/importer of cigarettes in this state to be and Taxation Code section 30163 and that the cigarettes are contained in packages that fully comply with the and that the cigarettes contained in those packages are the subject of filed reports that fully comply with all ANNUAL CERTIFICATION FOR MANUFACTURER/IMPORTER LICENSE be attached to this application BEFORE PREPARING below to certify this application If signed by an authorized agent a properly completed power of attorney must BOARD OF EQUALIZATION BOE 400 LMR (S1B) REV 2 (7 12) BOE 400 LMR (S1F) REV 2 (7 12)STATE OF CALIFORNIA BOE 400 LMR (S2) REV 2 (7 12) BOE USE ONLY Brand Family Names Your annual certification will not be processed if it is incomplete or not signed under BUSINESS TELEPHONE NUMBER by me and to the best of my knowledge and belief is a true correct and complete application CALIFORNIA CIGARETTE AND TOBACCO PRODUCTS LICENSING ACT OF 2003 Check box only if you have completed Section II Section III and/or Section IV of this form cigarettes manufactured or imported by that person and distributed in this state fully comply with Revenue City of: CITY ZIP CODE COMMISSION EXPIRES corporate resolution; and for a LLC attach the articles of organization which authorized the individual who signs Daytime telephone number: distributed in this state fully comply with subdivision (b) of section 30163 of the Revenue and Taxation Code EMAIL ADDRESS federal Cigarette Labeling and Advertising Act (15 U S C Sec 1331 et seq ) FILING REQUIREMENTS FROM: GENERAL INFORMATION I am no longer in business Date business discontinued: I certify that all the information provided in this certification is true and accurate and I understand that any I changed the ownership type of my business on: I hereby certify that this application including any accompanying schedules and statements has been examined If the original BOE 400 LMI2 Schedule of Cigarette Brand Family Names form you provided to the BOE in the If you need additional information please contact the State Board of Equalization Special Taxes and Fees P O Box in our field offices Please call our Taxpayer Information Section for assistance at 800 400 7115 (TTY:711) Information Section at 800 400 7115 (TTY:711); from the main menu select the option Special Taxes and Fees Customer licensed by the BOE Under the Act every manufacturer/importer must annually certify that all packages of licenses and permits using eRegistration (eReg) available on our website at www boe ca gov eReg is also available Mailing address: Make a copy of this document including any accompanying schedules for your records Manufacturer/importer certifies that all packages of cigarettes it manufactures or imports and that are manufacturer/importer must update the schedule of brand families that it manufactures or imports and provide manufacturer/importer or a listed brand is no longer manufactured or imported by the manufacturer/importer NAME (typed or printed) Names form and submit it with your renewal application Note:This document must also be signed and dated in front of an authorized notary public who also signs as Notice; Section III: Ownership Change; Section IV: Business Information Changes; Section V: Signature; page partner For a partnership attach an authorization signed by all general partners; for a corporation attach a person who asserts the truth of any material matter that he or she knows to be false is guilty of a misdemeanor Please use this address as my mailing address (check box and attach signed power of attorney form to use agent address for the account mailing address) PO BOX 942879 previous calendar year requires updating please complete the enclosed Schedule of Cigarette Brand Family PRINT NAME AND TITLE Products Licensing Act of 2003 under Division 8 6 (commencing with section 22970) of the California Business punishable by imprisonment of up to one year in the county jail or a fine of not more than five thousand dollars Pursuant to Chapter 4 of the California Business and Professions Code (commencing with section 22979) a RA B/A AUD REG READ INSTRUCTIONS reporting of ingredients added to cigarettes requirements of the federal Cigarette Labeling and Advertising Act (15 U S C Sec 1331 et seq ) for the RR QS FILE REF SACRAMENTO CA 94279 0088 Section I and Section VII SECTION I: CIGARETTE LICENSE ACCOUNT INFORMATION SECTION II: CANCELLATION NOTICE (complete this section only if you will not be maintaining your Cigarette License) SECTION III: OWNERSHIP CHANGE SECTION IV: BUSINESS INFORMATION CHANGES (complete this section only if you have changes to any of the fields below) SECTION V: SIGNATURE (this section must be completed if you made any changes to Sections II III or IV) SECTION VI: REQUIREMENT TO UPDATE SCHEDULE OF CIGARETTE BRAND FAMILY NAMES SECTION VII: CERTIFICATION FOR RENEWAL OF MANUFACTURER/IMPORTER LICENSE service representatives are available weekdays from 8:00 a m to 5:00 p m (Pacific time) except state holidays SIGNATURE SIGNATURE EMAIL ADDRESS SIGNATURE OF NOTARY PUBLIC SPECIAL TAXES AND FEES Subscribed and sworn to before me on this date: TELEPHONE TELEPHONE NUMBER TELEPHONE NUMBER The State Board of Equalization (BOE) is responsible for administering the California Cigarette and Tobacco This certification must be postmarked on or before the due date The annual certification consists of page This certification must be signed by a corporate officer LLC member or manager or an authorized agent or TITLE VII: Certification for Renewal of Manufacturer/Importer License; and BOE 400 LMI2 Schedule of Cigarette You must complete and return this annual certification to the BOE in order to maintain your cigarette license YOUR ACCOUNT NO

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