Form Dr 0222 - Cigarette Tax/tobacco Products Distributor Application - Department Of Revenue

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DR 0222 (04/01)
COLORADO DEPARTMENT OF REVENUE
BUSINESS TAX ACCOUNTING SECTION
1375 SHERMAN ST
DENVER CO 80261
(303) 205-8211 EXT. 6860
Cigarette Tax/Tobacco Products
Distributor Application
This form is to be used for new distributors only.
DO NOT WRITE IN THIS SPACE
Registration Number
Type of Ownership
INDIVIDUAL
GENERAL PARTNERSHIP
OTHER (specify):
CORPORATION
LIMITED PARTNERSHIP
___________________________
Taxpayer Name (owner, partners or corporation) (last, first, middle)
Trade Name/Doing Business As (if applicable)
Address of Principal Place of Business in Colorado (street) City
State
ZIP
County
City limits in which business is located (if applicable)
Telephone
(
)
Mailing Address (if different from above) (street or PO Box) City
State
ZIP
County
Telephone
FEIN/SSN
(
)
Brief description of business/What do you sell?
First Day of Business
•
CIGARETTE TAX LICENSE
The applicant agrees to accept the license or licenses, if granted, subject to the provisions of the Colorado Cigarette Tax Law,
House Bill 1086, enacted by the 44th General Assembly, Second Regular Session, 1964, and states that he/she is a wholesaler of
cigarettes in good faith in the State of Colorado.
1. License Fee
$
(29-09) (9)
Fee Schedule:
2. Surety Bond
July 1 - June 30
$
10.00
January 1 - June 30
$
5.00
$
(22-06) (14)
October 1 - June 30
7.50
April 1 - June 30
2.50
3. Certificate of Deposit
$
(22-06) (4)
A $1,000 bond must be posted with the Department of Revenue for each authorized
4. Cash Bond
metering machine, pursuant to House Bill 1086.
$
(22-06) (8)
TOBACCO PRODUCTS LICENSE
The applicant agrees to accept the license or licenses, if granted, subject to the provisions of the Colorado Tobacco Products Tax
Law, House Bill 1340, enacted by the 56th General Assembly, Regular Session, 1986, and states that he/she is a distributor of
tobacco products in good faith in the State of Colorado.
Fee Schedule:
5. License Fee
July 1 - June 30
$
10.00
January 1 - June 30
$ 5.00
$
(97-09) (9)
October 1 - June 30
7.50
April 1 - June 30
2.50
Make check payable to the
TOTAL CASH REMITTED
$
Colorado Department of Revenue
(add lines 1, 4 and 5)
I declare under penalty of perjury in the second degree that the statements made in this application are true and complete to the best
of my knowledge. (Signature required below.)
Type or Print Authorized Signature
Title
Signature of Owner, Partner, or Corporate Officer
Date

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