Form 2175 - Missouri Cigarette/other Tobacco Products Tax License Application Page 2

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PAGE 2

PREVIOUS OWNER INFORMATION

NAME OF PREVIOUS OWNER

NAME OF PREVIOUS BUSINESS

PREVIOUS LICENSE NUMBER

DATE BUSINESS CLOSED

__ __ /__ __ / __ __ __ __

PREVIOUS BUSINESS ADDRESS

CITY

STATE

ZIP CODE

COUNTY

__ __ __ __ __

IDENTIFY OWNERS, OFFICERS, PARTNERS, MEMBERS (ATTACH LIST IF ADDITIONAL SPACE IS REQUIRED.)

NAME (LAST, FIRST, MIDDLE INITIAL)

TITLE

SOCIAL SECURITY NO.

BIRTHDATE

__ __ __ -__ __ - __ __ __ __

__ __ / __ __ / __ __ __ __

HOME ADDRESS

CITY

STATE

ZIP CODE

COUNTY

EFFECTIVE DATE OF TITLE

_ _ _ _ _

_ _ / _ _ / _ _ _ _

NAME (LAST, FIRST, MIDDLE INITIAL)

TITLE

SOCIAL SECURITY NO.

BIRTHDATE

__ __ __ -__ __ - __ __ __ __

__ __ / __ __ / __ __ __ __

HOME ADDRESS

CITY

STATE

ZIP CODE

COUNTY

EFFECTIVE DATE OF TITLE

_ _ _ _ _

_ _ / _ _ / _ _ _ _

NAME (LAST, FIRST, MIDDLE INITIAL)

TITLE

SOCIAL SECURITY NO.

BIRTHDATE

__ __ __ -__ __ - __ __ __ __

__ __ / __ __ / __ __ __ __

HOME ADDRESS

CITY

STATE

ZIP CODE

COUNTY

EFFECTIVE DATE OF TITLE

_ _ _ _ _

_ _ / _ _ / _ _ _ _

If you are licensed for cigarette or other tobacco products in other states, please list the state and all license numbers.

REPORTING FORMS - ALL APPLICANTS MUST COMPLETE THIS SECTION

How do you want to receive reporting forms and updates?

(Check one)

I will download from the internet.

Please mail forms on a yearly basis.

ALL CIGARETTE TAX APPLICANTS MUST COMPLETE THIS SECTION

Indicate your stamping method:

Check the appropriate box indicating how you wish to purchase decals:

Meyercord Stamping Machine

Cash Basis

Credit Basis *

Cash and Credit Basis *

Heat applied

* Must post bond for amount of credit desired (contact our office at (573) 751-7163

Other _______________________________________________

for forms and instructions.)

The application must be signed by the owner, if the business is a sole proprietorship, by a partner, if the business is a partnership, or by a reported

officer, if the business is a corporation. The signature MUST be of the owner, partner, or officer as reported on this application.

I declare that the above information and any attachments are true, complete, and correct. I further certify under the penalty of perjury that I

will comply fully with sections 196.1020 through 196.1035, RSMo.

SIGNATURE

TITLE

DATE

__ __ / __ __ / __ __ __ __

PLEASE TYPE OR PRINT NAME

GENERAL INSTRUCTIONS

1. Cigarette wholesalers must complete the entire application. Attach all back-up documentation required for application.

2. Applicants for the other tobacco products license, or both cigarette and the other tobacco products licenses, are required to maintain a bond in

the amount of three times the average tax liability, estimated in the case of a new applicant. There is a $500.00 minimum. Call (573) 751-5772 to

request bond forms and/or additional information.

3. All applicants must submit a $100 license fee. Applicants applying for both cigarette and other tobacco products licenses may submit one

($100.00) license fee.

Mail the original application, bond form and all required documentation to: Taxation Division, Excise Tax, P.O. Box 811, Jefferson City,

Missouri 65105-0811. Retain a copy for your records.

If you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid may be presented again electronically.

If you have questions or need assistance in completing this form, please call (573) 751-7163 or e-mail excise@dor.mo.gov. You may also access the

department’s web site at TDD: (800) 735-2966

This publication is available upon request in alternative accessible format(s).

MO 860-0627 (07-2010)