Otp 1 - Application For Other Tobacco Products Distributor License Form - Ohio Department Of Taxation
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1OTP 1
Rev. 9/06
•
P.O. Box 530
Columbus, OH 43216-0530
Application for Other Tobacco Products Distributor License
For the period Feb. 1, 20
to Jan. 31, 20
Legal name
FEIN
DBA
Social security number
Street
Contact person
City
State
ZIP code
Telephone number
(
)
1. E-mail address:
If you wish to receive notification of any changes to the attorney general’s tobacco directory, please visit our Web site and
sign up for OH-TAX Alert (tax.ohio.gov/ohiotaxalert/isUserinfo.asp). When subscribing, clicking on the select all groups will
uncheck all of the taxes. You will then want to click on the tobacco (including MSA) box.
2. Business structure:
Sole owner
Partnership
Corporation
Fiduciary
Association
LLC
LLP
Other
3. Type of business:
Wholesale
Retail
Secondary distributor (purchasing tax-paid product for resale)
4. List below the titles, names, addresses and social security numbers of all corporate officers, association officers or
partners.
Title
Name
Address
Social Security No.
Federal Privacy Act
Because we require you to provide us with a Social Security
minister this tax. Your failure to supply any information re-
account number, the Federal Privacy Act of 1974 requires us
quested on a tax form prescribed by the tax commissioner
to inform you that your providing us your Social Security num-
may result in (i) the imposition of penalties for failing to file a
ber is mandatory. Ohio Revised Code sections 5703.05,
complete tax return or (ii) the denial of a license, if appli-
5703.057 and 5747.08 authorize us to request this informa-
cable.
tion. We need your Social Security number in order to ad-
I declare under penalties of perjury that the above statements have been examined by me and to the best of my knowledge and
belief are true, complete and correct.
Signature
Title
Date
A separate application is required for each business location. This is an annual license that must be renewed by Feb. 1 of each
year. Mail application and $100 application fee to the Ohio Department of Taxation, Excise Tax Section, P.O. Box 530, Colum-
bus, OH 43216-0530.
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