BOE-400-LMR (S1F) REV. 1 (7-07)
STATE OF CALIFORNIA
ANNUAL CERTIFICATION FOR MANUFACTURER/IMPORTER LICENSE
BOARD OF EQUALIZATION
BOARD USE ONLY
RA-B/A RR-QS AUD FILE REG REF
YOUR ACCOUNT NO. EFF
BOARD OF EQUALIZATION EXCISE TAXES DIVISION P O BOX 942879 SACRAMENTO CA 94279-0056
READ INSTRUCTIONS BEFORE PREPARING
CALIFORNIA CIGARETTE AND TOBACCO PRODUCTS LICENSING ACT OF 2003
GENERAL INFORMATION The State Board of Equalization (Board) is responsible for administering the California Cigarette and Tobacco Products Licensing Act of 2003 under Division 8.6 (commencing with section 22970) of the California Business and Professions Code (the Act). The Act requires every manufacturer/importer of cigarettes in this state to be licensed by the Board. Under the Act, every manufacturer/importer must annually certify that all packages of cigarettes manufactured or imported by that person and distributed in this State fully comply with Revenue and Taxation Code section 30163, and that the cigarettes are contained in packages that fully comply with the federal Cigarette Labeling and Advertising Act (15 U.S.C. Sec. 1331 et seq.). FILING REQUIREMENTS You must complete and return this annual certification to the Board in order to maintain your cigarette license. This certification must be postmarked on or before the due date. The annual certification consists of page (S1F) Section I: Cigarette License Account Information; page (S1B) which includes Section II: Cancellation Notice; Section III: Business Change; and Section IV: Signature; and page (S2) which consists of Section V: Requirement to Update Schedule of Brand Family Names and Section VI: Certification for Renewal of Manufacturer/Importer License; and Schedule of Brand Family Names (BOE-400-LMI2). Your annual certification will not be processed if it is incomplete or not signed under Section I and Section VI.
SECTION I: CIGARETTE LICENSE ACCOUNT INFORMATION
Check box only if you have completed Section II and/or Section III of this form.
I hereby certify that this application, including any accompanying schedules and statements, has been examined by me and to the best of my knowledge and belief is a true, correct and complete application.
YOUR SIGNATURE AND TITLE TELEPHONE NUMBER DATE
Make a copy of this document for your records.
(continued on reverse)
BOE-400-LMR (S1B) REV. 1 (7-07)
SECTION II: CANCELLATION NOTICE (complete this section if you will not be maintaining your Cigarette License) I am not maintaining my Manufacturer/Importer Cigarette License because (check only one box) I am no longer in business. Date business discontinued: Please provide your current daytime telephone number and address:
Other (please explain)
SECTION III: BUSINESS CHANGE (complete this section only if the information preprinted on the front of this application is incorrect or if there has been a change in the ownership of the business)
1) TYPE OF NEW OWNERSHIP
Sole Owner Corporation
Husband & Wife Co-Partnership Limited Liability Company (LLC)
Limited Partnership (LP)
Limited Liability Partnership (LLP)
Registered Domestic Partnership
Other (describe) __________________
2) NEW CORPORATION/LLC NAME AND NUMBER (list names of corporate/LLC officers, members or managers below)
3) NEW OWNER/PARTNER/PRESIDENT NAME
4) NEW BUSINESS OR TRADE NAME/DBA
5) NEW LOCATION OF BUSINESS (do not use a PO Box or agent's address for location of business)
DAYTIME TELEPHONE NUMBER
6) NEW MAILING ADDRESS (if different from business location; do not enter agent's address here)
DAYTIME TELEPHONE NUMBER
7) NEW AGENT/BOOKKEEPER NAME 8) NEW AGENT/BOOKKEEPER TELEPHONE NUMBER
9) NEW AGENT/BOOKKEEPER MAILING ADDRESS
Please use this address as my mailing address. (check box and attach signed power of attorney form to use agent address for the account mailing address)
SECTION IV: SIGNATURE (this section must be completed, if you made any changes to Section II or III)
BOE-400-LMR (S2) REV. 1 (7-07)
SECTION V: REQUIREMENT TO UPDATE SCHEDULE OF BRAND FAMILY NAMES
Pursuant to Chapter 4 of the California Business and Professions Code (commencing with section 22979), a manufacturer/importer must update the schedule of brand families that it manufactures or imports and provide a copy to the Board whenever a new or additional brand is manufactured or imported by the manufacturer/importer, or a listed brand is no longer manufactured or imported by the manufacturer/importer. If the original Schedule of Brand Family Names form, (BOE-400-LMI2), you provided to the Board for calendar year 2004 requires updating, please complete, the attached Schedule of Brand Family Names form and return it to the State Board of Equalization, PO Box 942879, Sacramento, CA 94279-0056.
SECTION VI: CERTIFICATION FOR RENEWAL OF MANUFACTURER/IMPORTER LICENSE
Manufacturer/importer certifies that all packages of cigarettes it manufactures or imports and that are distributed in this state fully comply with subdivision (b) of section 30163 of the Revenue and Taxation Code, and that the cigarettes contained in those packages are the subject of filed reports that fully comply with all requirements of the federal Cigarette Labeling and Advertising Act (15 U.S.C. Sec. 1331 et seq.) for the reporting of ingredients added to cigarettes. I certify that all the information provided in this certification is true and accurate and I understand that any person who asserts the truth of any material matter that he or she knows to be false is guilty of a misdemeanor punishable by imprisonment of up to one year in the county jail, or a fine of not more than five thousand dollars ($5,000), or both the imprisonment and the fine. This certification must be signed by a corporate officer, LLC member or manager, or an authorized agent, or partner. For a partnership, attach an authorization signed by all general partners; for a corporation, attach a corporate resolution; and for a LLC, attach the articles of organization which authorized the individual who signs below to certify this application. If signed by an authorized agent, a properly completed power of attorney must be attached to this application. Note: This document must also be signed and dated in front of an authorized notary public, who also signs as a witness.
NAME (typed or printed)
Subscribed and sworn to before me on this date: City of:
SIGNATURE OF NOTARY PUBLIC
If you wish additional information, please contact the State Board of Equalization, Excise Taxes Division, 450 N Street, P.O. Box 942879, Sacramento, CA 94279-0056, Telephone 800-400-7115.