Form BOE-400-LRR Fillable Renewal Application for Retailer's Cigarette and Tobacco Products License

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Download Form BOE-400-LRR

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(1 Enter the total number of retail locations that you operate at which cigarettes and/or tobacco products are sold and for which you are applying for renewal (from Schedule A if more than one location) ) (2) NEW CORPORATION/LLC NAME AND NUMBER (list names of corporate/LLC officers members or managers below)) (3) NEW OWNER/PARTNER/PRESIDENT NAME) (4) NEW BUSINESS OR TRADE NAME/DBA) (5) NEW LOCATION OF BUSINESS (do not use a PO Box or agent's address for location of business)) (6) NEW MAILING ADDRESS (if different from business location; do not enter agent's address here)) (7) NEW AGENT/BOOKKEEPER NAME) (8 NEW AGENT/BOOKKEEPER (AREA CODE)) (8) NEW AGENT/BOOKKEEPER TELEPHONE NUMBER) (ACCOUNT NUMBER:) (BOE USE ONLY) (button) PRINT (continued on reverse) (Date business discontinued:) (DATE) (DAYTIME TELEPHONE (AREA CODE)) (DAYTIME TELEPHONE NUMBER) (EMAIL ADDRESS) (including (including each general partner and each person who has control as defined in California Business and Professions Code section (must provide if not listed below) (NEW AGENT/BOOKKEEPER MAILING ADDRESS) (Other (describe)) (OWNER NAME:) (PERIOD:) (Please provide your current daytime telephone number and address:) (PRINT NAME AND TITLE) (Row 1 B O E Use Only) (Row 1 C TELEPHONE NUMBER (including area code) ) (Row 1 D EMAIL ADDRESS ) (Row 1 E ENTER "1" IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (Row 10 E ENTER "1" IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (Row 2 E ENTER "1" IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (Row 3 E ENTER "1" IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (Row 4 E ENTER "1" IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (Row 5 E ENTER "1" IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (Row 6 E ENTER "1" IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (Row 7 B O E Use Only) (Row 7 E ENTER "1" IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (Row 8 B O E Use Only) (Row 8 E ENTER "1" IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (Row 9 B O E Use Only) (Row 9 E ENTER "1" IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (TELEPHONE (AREA CODE)) (TELEPHONE NUMBER (AREA CODE)) (TELEPHONE NUMBER) (text) (text) (text) (the Act) The Act requires every retailer of cigarettes and/or tobacco products in this state to be licensed by the BOE Under (TOTAL NUMBER OF LICENSES REQUIRED:) (YOUR ACCOUNT NO ) [ FOID ] 1 Enter the total number of retail locations that you operate at which cigarettes and/or 1) PLEASE CHECK TYPE OF NEW OWNERSHIP 2) NEW CORPORATION/LLC NAME AND NUMBER (list names of corporate/LLC officers members or managers below) 22971(p)) pertaining to the manufacture sale or distribution of cigarettes and/or tobacco products The applicant (including each 22980 2) and can result in a seizure of product penalty and/or fine 3) NEW OWNER/PARTNER/PRESIDENT NAME 4) NEW BUSINESS OR TRADE NAME/DBA 5) NEW LOCATION OF BUSINESS (do not use a PO Box or agent's address for location of business) DAYTIME TELEPHONE NUMBER 6) NEW MAILING ADDRESS (if different from business location; do not enter agent's address here) 7) NEW AGENT/BOOKKEEPER NAME 8) NEW AGENT/BOOKKEEPER TELEPHONE NUMBER 9) NEW AGENT/BOOKKEEPER MAILING ADDRESS 942879 Sacramento CA 94279 0088 You may also visit the BOE website at www boe ca gov or call the Taxpayer A retailer must conspicuously (that is easily seen by customers) display the license at each retail location ACCOUNT NUMBER: agrees to comply with the reporting payment record keeping and license display requirements as specified in the Cigarette and an LLC attach articles of organization which authorize the individual who signs below to certify this application If and Tobacco Products Licensing Act of 2003 or any rule of the State Board of Equalization (BOE) applicable to the applicant and you receive your renewal Cigarette and Tobacco Products Retailer's License Any sales or purchases of cigarettes and/or area code) asserts the truth of any material matter that he or she knows to be false is guilty of a misdemeanor punishable by imprisonment AT THIS LOCATION be processed if it is incomplete or not signed under both Section I and Section IV BEFORE PREPARING BOARD OF EQUALIZATION BOARD OF EQUALIZATION BOE 400 LRR (S1B) REV 6 (4 13) BOE 400 LRR (S1F) REV 6 (4 13) STATE OF CALIFORNIA BOE 400 LRR (S2) REV 6 (4 13) BOE USE ONLY BUSINESS ADDRESS BUSINESS NAME 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 and/or Section III of this form Check box to affirm that none of the retail locations included in line 1 are "special purpose commercial coaches " (for example catering trucks lunch wagons or other mobile facilities) Corporation cost to renew your license provided this form is postmarked on or before the due date Your renewal application will not DAYTIME TELEPHONE NUMBER EMAIL ADDRESS ENTER "1" FILING REQUIREMENTS GENERAL INFORMATION general partner and each person who has control as defined in California Business and Professions Code section 22971(p)) also I affirm that the applicant (including each general partner and each person who has control as defined in California Business and I am no longer in business Date business discontinued: I certify that all the information provided in this application is complete true and accurate and I understand that any person who I hereby certify that this application including any accompanying schedules and statements has been examined IF CIGARETTE OR If you need additional information please contact the State Board of Equalization Special Taxes and Fees P O Box In order to maintain your cigarette and tobacco products license you must complete and return this renewal application to Information Section at 1 800 400 7115 (TTY:711); from the main menu select the option "Special Taxes and Fees " Licensing Act of 2003 under Division 8 6 (commencing with section 22970) of the California Business and Professions Code Limited Liability Company (LLC) Limited Liability Partnership (LLP) Limited Partnership (LP) Make a copy of this document for your records Married Co Partnership more than one location) nature of any violation or reasons that will prevent you from complying with the requirements with respect to the statement ) Note: The submission of this renewal application does not allow you the privilege of selling or purchasing cigarettes and/or Note: This must be signed by an owner partner corporate officer LLC member or manager or by an authorized agent For a NUMBER of up to one year in county jail or a fine of not more than one thousand dollars ($1 000) or both the fine and imprisonment or on the enclosed Schedule A if applicable is incorrect or if there has been a change in the ownership of the business) Other (describe) OWNER NAME: Partnership partnership attach authorization signed by all general partners; for a corporation attach corporate resolution; and for PERIOD: Please provide your current daytime telephone number and address: Please use this address as my mailing address (check box and attach signed power of attorney form to use agent's address for the account mailing address) PO BOX 942879 PRINT NAME AND TITLE Products Retailer's License) products without a valid Cigarette and Tobacco Products Retailer's License Professions Code (If you are unable to affirm this statement you must provide the BOE with a separate statement containing the Professions Code section 22971(p)) has not been convicted of a felony under sections 30473 or 30480 of the Revenue and RA B/A AUD REG READ INSTRUCTIONS Registered Domestic Partnership RENEWAL APPLICATION FOR RETAILER'S CIGARETTE AND TOBACCO PRODUCTS LICENSE Retailers who have allowed their Cigarette and Tobacco Products Retailer's License to expire and failed to renew RR QS FILE REF SACRAMENTO CA 94279 0088 SCHEDULE A RETAIL LOCATIONS RENEWAL SECTION I: CIGARETTE AND TOBACCO PRODUCTS LICENSE ACCOUNT INFORMATION SECTION II: CANCELLATION NOTICE (complete this section if you will not be renewing your Cigarette and Tobacco Section II: Cancellation Notice; Section III: Business Change; Section IV: Signature; and Schedule A (if enclosed) There is no SECTION III: BUSINESS CHANGE (complete this section only if the information preprinted on the front of this application SECTION IV: SIGNATURE (this section must be completed if you made any changes to Section II or III) SIGNATURE EMAIL ADDRESS signed by an authorized agent a properly completed power of attorney form must be attached to this application Sole Owner Special purpose commercial coaches can not be registered as retail locations SPECIAL TAXES AND FEES STATE OF CALIFORNIA Taxation Code and has not violated and will not violate or cause or permit to be violated any of the provisions of the Cigarette TELEPHONE TELEPHONE the Act every retailer must obtain a separate license for each location at which cigarettes and/or tobacco products are sold the BOE The renewal application consists of Section I: Cigarette and Tobacco Products License Account Information; The State Board of Equalization (BOE) is responsible for administering the California Cigarette and Tobacco Products timely are required to pay a fee of $100 00 to have a license reinstated The reinstatement fee applies to each license TOBACCO PRODUCTS tobacco products are sold and for which you are applying for renewal (from Schedule A if tobacco products before receipt of a license constitutes a violation of the Act (Business and Professions Code section tobacco products in California You cannot legally sell cigarettes and/or tobacco products until your application is processed Tobacco Products Licensing Act of 2003 under Division 8 6 (commencing with section 22970) of the California Business and TOTAL NUMBER OF LICENSES REQUIRED: which has expired and was not renewed timely Please remember you may not sell cigarettes and/or tobacco WILL BE SOLD YOUR ACCOUNT NO

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