Free 400acts-rev1-8-05 p65.p65 - California

BOE-400-ACTS (FRONT) REV. 2 (6-07)

STATE OF CALIFORNIA

APPLICATION FOR LICENSED CIGARETTE DISTRIBUTOR TO REGISTER CIGARETTE TAX STAMP PURCHASER

BOARD OF EQUALIZATION

Please print or type - instructions are available on the reverse of this form.
1. THIS APPLICATION IS FOR CIGARETTE TAX STAMP PURCHASER (please check one)

New

Revised

Reinstatement

INFORMATION ABOUT BOE ACCOUNT FOR wHICH CIGARETTE TAX STAMPS wILL BE PURCHASED
2. CIGARETTE DISTRIBUTOR ACCOUNT NUMBER

CR ET 023. CIGARETTE DISTRIBUTOR NAME

4. CIGARETTE DISTRIBUTOR E-MAIL ADDRESS

AUTHORIzED CIGARETTE TAX STAMP PURCHASER FOR THE ABOvE ACCOUNT
5. NAME OF PERSON AUTHORIZED TO PURCHASE CIGARETTE TAX STAMPS IS PURCHASER REGISTERED FOR ANOTHER CIGARETTE DISTRIBUTOR ACCOUNT? (check one)

Yes
6. CONTACT PHONE NUMBER 7. FAX NUMBER

No If yes, Account No. __________________________

8. E-MAIL ADDRESS OF PERSON AUTHORIZED TO PURCHASE STAMPS

9. PLEASE COMPLETE THE FOLLOWING FOR AUTHENTICATION OR IDENTIFICATION

Personal Identification Code (must be four numeric digits):
10. DOES THE PURCHASER INTEND TO ORDER CIGARETTE TAX STAMPS THROUGH THE INTERNET?

Yes

No

11. NAME AND TITLE OF THE DISTRIBUTOR'S PRINCIPAL OWNER OR AUTHORIZED REPRESENTATIVE

12. SIGNATURE OF THE DISTRIBUTOR'S PRINCIPAL OWNER OR AUTHORIZED REPRESENTATIVE

DATE

NOTE TO SIGNATORy: If you are not a corporate officer, partner, or owner, this signature certifies under penalty of perjury that you hold a power of attorney to authorize permission to order cigarette stamps.
13. SIGNATURE OF AUTHORIZED PURCHASER DATE

-

CLEAR

PRINT

BOE-400-ACTS (BACK) REV. 2 (6-07)

INSTRUCTIONS General Information
Overview The Board of Equalization (Board) has implemented a new system for the sale and delivery of cigarette tax stamps. This new system requires you to register persons authorized to order cigarette tax stamps for your account. We require you to complete this form to ensure that only authorized individuals can make stamp purchases for your account. who needs to apply Licensed cigarette distributors must provide the requested information for each person authorized to make stamp purchases. You must designate at least one person to purchase stamps for your account. You must submit a separate application for each person that you authorize to make stamp purchases. If you have multiple accounts, separate applications must be submitted for each account. when to file application You must file your application before stamps are ordered. The Board will not sell stamps to you unless you have completed this application and received approval to purchase stamps under the new system. where to file application Send your completed application to: State Board of Equalization Excise Taxes Division, MIC:56 PO Box 942879 Sacramento, CA 94279-0056

If you have questions related to registration Please call 800-400-7115.

Specific Instructions
Line 1 Line 2 Line 3 Line 4 Check the appropriate boxes. Enter your Board of Equalization cigarette distributor account number. Enter the legal name of the cigarette distributor account. Enter the e-mail address of the cigarette distributor. If you provide an e-mail address on form BOE-400-ACTS, we will e-mail you to confirm the cigarette tax stamp purchaser registration. If you do not provide an e-mail address, we will send you a letter confirming the cigarette tax stamp purchaser registration. Enter the name of the person authorized to purchase cigarette tax stamps, and indicate if that person is registered for another cigarette distributor account. If an authorized purchaser is registered for another account, indicate that account number. Enter the telephone number for the person you are authorizing to purchase cigarette tax stamps. Enter the fax number for the person you are authorizing to purchase cigarette tax stamps. Enter the e-mail address for the person you are authorizing to purchase cigarette tax stamps. Enter a four numeric digit personal identification code on line 5. This information will be used for authentication purposes to safeguard your account. Indicate if you intend to order cigarette tax stamps through the Internet. Enter the name of the person authorized to act and sign for your cigarette distributor account in legal matters. The form must be signed by the person listed on line 11. An original signature is required to complete this application. The form must be signed by the authorized purchaser listed on line 5. An original signature is required to complete this application.

Line 5

Line 6 Line 7 Line 8 Line 9 Line 10 Line 11 Line 12 Line 13