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Application For Cigarette Distributors Registration Certificate CIG-1A - Indiana

Application For Cigarette Distributors Registration Certificate Form. This is a Indiana form and can be used in Cigarette Department Of Revenue Statewide .
 Fillable pdf Last Modified 1/16/2008
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INDIANA DEPARTMENT OF REVENUE P.O. BOX 901 INDIANAPOLIS, IN 46206-0901 CIG - 1A Rev. 7-97 SF 48477 FOR OFFICE USE ONLY CIG APPLICATION FOR CIGARETTE DISTRIBUTOR'S REGISTRATION CERTIFICATE Renewal New Certificate Applicant's Name - Enter individual, partnership, or corporation name Business/Trade Name (if different than above) Mailing Address (Street or P.O. Box Number) Location Address of Business (if different than above) Telephone Number City or Town City or Town County County Federal ID Number Owner's Social Security # State State Zip Code Zip Code Type of Ownership: Sole Proprietorship Partnership Corporation If Corporation: Date of Incorporation: If Foreign Corporation: Date of Acceptance by Indiana Secretary of State: If an Indiana Corporation or a Foreign Corporation, Give Name and Address of Resident Agent: Identification of Partners or Corporate Officers: Name (last name first) Social Security Number Address City State Zip Code Title Does Applicant Presently Hold an OTP Tax Certificate? Certificate Number: Does Applicant Presently Hold a Cigarette Tax Certificate? Certificate Number: Has Applicant Previously Held a Cigarette Tax Certificate? Certificate Number: Does Applicant Presently Hold an Indiana Registered Retail Merchants Certificate? Certificate Number: Does Applicant Presently Hold Any Other License or Permits Issued by any State Agency? STATE AGENCY TYPE OF LICENSE OR PERMIT NUMBER American LegalNet, Inc. www.FormsWorkflow.com Audit Information: Location Where Records Will Be Available For Audit: Phone Number of Location Of Audit Records: Phone Number of Business Location: Indicate Address and Certificate Number of Each Location In Which You Have Cigarettes in Storage Location Cigarette Number From What Source do you intend to buy Cigarettes? _____ A. Direct from Manufacturer _____ B. Wholesaler outside the State of Indiana: Unstamped ________ Stamped________ _____ C. Indiana Distributor: Unstamped ________ Stamped ________ IF YOU INTEND TO PURCHASE CIGARETTES PRESTAMPED FOR RESALE IN INDIANA, YOU MUST PROVIDE THE FOLLOWING INFORMATION FOR AT LEAST TEN CUSTOMERS. RETAILER 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. ADDRESS PHONE NUMBER RETAIL MERCHANTS CERTIFICATE NUMBER Does Your Company Expect to Sell Cigarettes Into Another State? Yes _____ No_____ If Yes, List the State(s) and License/Certificate Number(s): I hereby declare under penalties of perjury that the information contained in this return, including accompanying schedules and statements, is true, correct and complete to the best of my knowledge and belief. Signature of Taxpayer or Agent Title Telephone Number () Date American LegalNet, Inc. www.FormsWorkflow.com
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