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Form BOE-400-LTE Fillable Certification for Manufacturer/Importer Tobacco Products License
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)(1)A list of all distributors licensed pursuant to section 22975 to which the manufacturer or importer shipped its tobacco products or (1)Five times the retail value of the seized cigarettes or tobacco products defined as cigarettes under this section or (2)Five thousand dollars ($5 000) (2)The total wholesale cost of the products (a)In the case of the first offense the BOE may revoke or suspend the license or licenses of the manufacturer or importer pursuant to (b)In the case of a second or any subsequent offense in addition to the action authorized under subdivision (a) the BOE may impose (CLEAR) CLEAR (Date) (Date) (Date) (DATE) (EMAIL ADDRESS) (eREG ID#) (Initial) (Initial) (Initial) (NAME (typed or printed) (PRINT) PRINT (TELEPHONE NUMBER) (TITLE) 1 All of the information contained in the completed Application and Schedule of Tobacco Products Brand Family Names is complete true 2 If the applicant is a "tobacco product manufacturer" as defined in subdivision (i) of section 104556 of the Health and Safety Code the 3 Applicant consents to jurisdiction of the California courts for the purpose of enforcement of the California Cigarette and Tobacco Products 4 Applicant certifies that it shall file a monthly report to the BOE in a manner specified by the BOE which may include but is not limited to 5 Applicant understands and acknowledges that under California Business and Professions Code section 22980 1 no manufacturer shall 6 Applicant understands and acknowledges that under California Business and Professions Code section 22979 7 in addition to any other A "participating manufacturer" as defined in subsection II(jj) of the "Master Settlement Agreement" (MSA) or a civil penalty in an amount not to exceed the greater of: a fine of not more than five thousand dollars ($5 000) or both the imprisonment and the fine and correct and Tobacco Products Licensing Act of 2003 the BOE may take the following actions: applicant certifies it is one of the following (check appropriate box): attorney must be attached to this application authorization signed by all general partners; for a corporation attach a corporate resolution; for an LLC attach the articles of incorporation been suspended or revoked Failure to comply with this section shall be a misdemeanor subject to penalties and fines pursuant to BOARD OF EQUALIZATION BOE 400 LTE REV 1 (5 12)STATE OF CALIFORNIA CA 94279 0088 California Business and Professions Code section 22981 California Office of the Attorney General caused its tobacco products to be shipped CERTIFICATION CERTIFICATION FOR MANUFACTURER/IMPORTER TOBACCO PRODUCTS LICENSE civil or criminal penalty provided by law upon finding that a manufacturer or importer has violated any provision of the California Cigarette Complete this form and mail it to the Board of Equalization Special Taxes and Fees P O Box 942879 Sacramento Date: Date: Date: electronic media pursuant to California Business and Professions Code section 22979 21 The monthly report shall include but is not EMAIL ADDRESS eREG ID# I certify that all the information provided in this application is true and accurate and I understand that any person who asserts the truth of any Initial: Initial: Initial: Is in full compliance with paragraph (2) of subdivision (a) of section 104557 of the Health and Safety Code Licensing Act of 2003 and has appointed a registered agent for service of process and identified the registered agent to the BOE and the limited to the following: material matter that he or she knows to be false is guilty of a misdemeanor punishable by imprisonment of up to one year in the county jail or NAME (typed or printed) On behalf of the above manufacturer or importer the undersigned certifies the following: sell cigarettes or tobacco products to a distributor wholesaler importer or any other person who is not licensed or whose license has SIGNATURETITLE TELEPHONE NUMBER the procedures applicable to the revocation of a license set forth in section 30148 of the Revenue and Taxation Code This form must be signed by a corporate officer LLC member or manager or an authorized agent or partner For a partnership attach an which authorized the individual who signs below to certify this application If signed by an authorized agent a properly completed power of