Form 5422 - Missouri Tobacco Directory - Supplemental Cigarette And Roll Your Own (Ryo) Packaging Change Notification

Download a blank fillable Form 5422 - Missouri Tobacco Directory - Supplemental Cigarette And Roll Your Own (Ryo) Packaging Change Notification in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 5422 - Missouri Tobacco Directory - Supplemental Cigarette And Roll Your Own (Ryo) Packaging Change Notification with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Print Form

Reset Form

MISSOURI DEPARTMENT OF REVENUE

FORM

TAXATION DIVISION

5422

P.O. BOX 811 JEFFERSON CITY, MO 65105-0811

MISSOURI TOBACCO DIRECTORY - SUPPLEMENTAL CIGARETTE AND

ROLL YOUR OWN (RYO) PACKAGING CHANGE NOTIFICATION

(REV. 09-2012)

PART 1: CURRENT CALENDAR YEAR

FOR OFFICE

CURRENT CALENDAR YEAR FOR

____________

USE ONLY

THIS NOTIFICATION:

Postmark Date:

PART 2: MANUFACTURER

Name:

Federal I.D. Number:

__ __ __ __ __ __ __ __ __

Mailing Address:

City:

State:

Zip Code:

Country:

__ __ __ __ __

Physical Address:

City:

State:

Zip Code:

Country:

__ __ __ __ __

Telephone Number:

Fax Number:

E-mail Address:

__ __ __ __ __ __ __ __ __ __ __ __ __ __

PART 3: BRAND FAMILY AND BRAND STYLE IDENTIFICATION

Check the appropriate box(es) and attach additional sheets if necessary:

Effective Date of Change(MM/DD/YYYY): ______________________

Supplemental Certification: Included is sample cigarette or RYO

Description of Change: _____________________________________

packaging (without tobacco) for each brand style listed below.

________________________________________________________

Actual packaging (without tobacco)

________________________________________________________

Electronic copy of packaging

CONTAINER

CHECK ONE

BRAND FAMILY

BRAND STYLE

SIZE

FLAVOR

CIGARETTE

RYO

CIGARETTE

RYO

CIGARETTE

RYO

CIGARETTE

RYO

CIGARETTE

RYO

CIGARETTE

RYO

CIGARETTE

RYO

PART 4: EXECUTION BY AUTHORIZED PERSON

The undersigned certifies that as of the date of this notification, the above-named company is a tobacco product manufacturer of cigarettes and/or RYO. I certify the above

information is a change to packaging only and that no changes have occurred to the brand family, brand style, ingredients, blend, tipping or paper of the actual cigarettes

and/or RYO as originally certified to the Missouri Department of Revenue and the Missouri Fire Marshal.

Under penalty of perjury, I certify and declare that all of the statements contained in this certification, including but not limited to any accompanying statements or attachments

herewith, are true, correct, accurate and complete in every particular, and that I am a person authorized to bind the tobacco product manufacturer making this notification

either under the laws of the state of Missouri or the jurisdiction where the manufacturer resides or is organized. Any violation of the requirements of sections 196.1003

and 196.1020 to 196.1035, RSMo, is basis for removal of the company’s brands from Missouri’s Directory of Compliant Tobacco Products Manufacturers.

Signature of Authorized Person:

Date(MM/DD/YYYY):

Printed Name:

Title:

Mail the original notification

Mail copies of original notification

and all supporting documents to:

NOTARY PUBLIC

MISSOURI ATTORNEY GENERAL

MISSOURI DEPARTMENT OF REVENUE

Taxation Division