Form Otp 1 - Application For Other Tobacco Products Distributor License
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1OTP 1
Rev. 11/11
Reset Form
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 notifi cation 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 g r o u p s
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 offi cers, association offi cers or part-
ners.
Title
Name
Address
Social Security No.
Federal Privacy Act
Because we require you to provide us with a Social Security
5703.05, 5703.057 and 5747.08 authorize us to request this
account number, the Federal Privacy Act of 1974 requires
information. Social Security numbers are needed in order
us to inform you that your providing us your Social Security
to administer this tax due to responsible party obligations
number is mandatory. Ohio Revised Code sections (R.C.)
authorized by R.C. 5743.57.
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. If this is a renewal license, there is a $1,000 application fee. If this is a new application mailed after Feb. 1, please
use the proration chart found on our Web site to determine the application fee. Mail the application and the fee to the Ohio
Department of Taxation, Excise Tax Section, P.O. Box 530, Columbus, OH 43216-0530.
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