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Form BOE-400-LTR Fillable Renewal Application for Manufacturer/Importer Tobacco Products License
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)(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) (ADDRESS) (BOE USE ONLY) (BOE USE ONLY) (BUSINESS TELEPHONE NUMBER (AREA CODE)) (BUSINESS TELEPHONE NUMBER) (CITY) (CLEAR) CLEAR (continued on reverse) (Date business discontinued:) (DATE) (DATE) (Daytime telephone number:) (EMAIL ADDRESS) (EMAIL ADDRESS) (FROM:) (I changed the ownership type of my business on:) (Mailing address:) (Mailing address:) (NAME (typed or printed)) (PRINT NAME AND TITLE) (PRINT) PRINT (STATE) (TELEPHONE (AREA CODE)) (TELEPHONE NUMBER (AREA CODE)) (TELEPHONE NUMBER (AREA CODE)) (TELEPHONE NUMBER) (TELEPHONE NUMBER) (TELEPHONE) (text) (TITLE) (TO:) (YOUR ACCOUNT NO ) (ZIP CODE) (ZIP CODE) [ FOID] 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) 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 witness ADDRESS all distributors licensed pursuant to section 22975 to which the manufacturer or importer shipped its tobacco and Professions Code) Assembly Bill 1749 (Statutes 2006 chapter 501) requires every manufacturer or 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 LTR (S1B) REV 1 (7 12) BOE 400 LTR (S1F) REV 1 (7 12) STATE OF CALIFORNIA BOE 400 LTR (S2) REV 1 (7 12) BOE USE ONLY Both chewing tobacco or snuff and other tobacco products both imprisonment and fine 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 certification consists of page (S1F) Section I: Tobacco Products Manufacturer/Importer License Account Check box only if you have completed Section II Section III and/or Section IV of this form Chewing tobacco or snuff chewing tobacco snuff or other tobacco products must annually obtain and maintain a license to engage in City of: CITY STATE Code section 22981 COMMISSION EXPIRES copy to the BOE whenever a new or additional brand is manufactured or imported by the corporate resolution; and for a LLC attach the articles of organization which authorized the individual who signs Daytime telephone number: EMAIL ADDRESS 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 understand that any person 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 you need additional information please contact the State Board of Equalization Special Taxes and Fees P O Box importer of tobacco products to be licensed under the Act Under the Act every manufacturer or importer of Importer Report of Tobacco Products Delivered or Shipped Into California to the BOE in a manner specified by 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 Information; page (S1B) which includes Section II: Cancellation Notice; Section III: Ownership Change; Section It is understood and acknowledged that under California Business and Professions Code section 22980 1 no IV: Business Information Changes; and Section V: Signature; page (S2) which consists of Section VI: 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 and any accompanying schedules for your records manufacturer or importer must update the list of brand family names it manufactures or imports and provide a Manufacturer/Importer certifies that they shall file a monthly report BOE 501 MIT Schedule Manufacturer/ manufacturer/importer license This certification must be postmarked on or before the due date The annual manufacturer/importer or a listed brand is no longer manufactured or imported manufacturer/importer shall sell cigarettes or tobacco products to a distributor wholesaler importer or any NAME (typed or printed) Note:This document must also be signed and dated in front of an authorized notary public who also signs as Only tobacco products other than chewing tobacco or snuff other person who is not licensed or whose license has been suspended or revoked Failure to comply with this partner For a partnership attach an authorization signed by all general partners; for a corporation attach a Please check the tobacco product you are currently manufacturing or importing (check only one box): Please complete and submit with your renewal application and certification; BOE 400 LT1 Schedule of 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 PRINT NAME AND TITLE Products Brand Family Names Your annual certification will not be processed if it is incomplete or not signed Products License) Products Licensing Act of 2003 under Division 8 6 (commencing with section 22970 of the California Business products or caused its tobacco products to be shipped and the total wholesale cost of the products Professions Code section 22979 21 The monthly report shall include but is not limited to the following: a list of punishable by imprisonment of up to one year in jail or a fine of not more than five thousand dollars ($5 000) or Pursuant to California Business and Professions Code section 22979 21 in order to maintain a license a RA B/A AUD REG READ INSTRUCTIONS RENEWAL APPLICATION FOR MANUFACTURER/IMPORTER Renewal of Tobacco Products Manufacturer/Importer License; and BOE 400 LT1 Schedule of Tobacco Requirement to Update Schedule of Tobacco Products Brand Family Names and Section VII: Certification for RR QS FILE REF SACRAMENTO CA 94279 0088 SECTION I: TOBACCO PRODUCTS MANUFACTURER/IMPORTER LICENSE ACCOUNT INFORMATION SECTION II: CANCELLATION NOTICE (complete this section only if you will not be maintaining your Tobacco SECTION III: OWNERSHIP CHANGE SECTION IV: BUSINESS INFORMATION CHANGES (complete this section only if you have changes to any of the fields below) section shall be a misdemeanor subject to penalties and fines pursuant to California Business and Professions 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 TOBACCO PRODUCTS BRAND FAMILY NAMES SECTION VII: CERTIFICATION FOR RENEWAL OF TOBACCO PRODUCTS 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 BOE which may include but is not limited to electronic media pursuant to California Business and the sale of tobacco products The State Board of Equalization (BOE) is responsible for administering the California Cigarette and Tobacco This certification must be signed by a corporate officer LLC member or manager or an authorized agent or TITLE Tobacco Products Brand Family Names included with this Renewal Application TOBACCO PRODUCTS LICENSE under Section I and Section VII who asserts the truth of any material matter that he or she knows to be false is guilty of a misdemeanor You must complete and return this annual certification to the BOE in order to maintain your tobacco products YOUR ACCOUNT NO ZIP CODE