Free Cigarette Distributor's Application for Deferred Payment Option - California

BOE-356 REV. 1 (2-08)

STATE OF CALIFORNIA

CIGARETTEDISTRIBUTOR'S APPLICATIONFORDEFERREDPAYMENTOPTION
BUSINESS NAME

BOARD OF EQUALIZATION

DISTRIBUTOR PERMIT NUMBER

CRET02AMOUNT OF DEFERRED CREDIT REQUESTED

$
PAYMENT OPTION (please check only one)

Weekly payment without a security deposit
Monthly payment

Weekly payment with a security deposit Twice-Monthly payment
CONTACT TELEPHONE NUMBER

CIGARETTE DISTRIBUTOR E-MAIL ADDRESS (e-mail address of designated person responsible for payment processing)

( On behalf of the above distributor, the undersigned certifies the following:

)

Cigarette distributor voluntarily and freely elects to make deferred payments for purchases of cigarette tax stamps or meter register settings based on the designated option chosen above for a period of at least one year from the date the election is made in accordance with section 30168 of the Cigarette and Tobacco Products Tax Law.
NAME AND TITLE OF DISTRIBUTOR'S PRINCIPAL OWNER OR AUTHORIZED REPRESENTATIVE

SIGNATURE OF DISTRIBUTOR'S PRINCIPAL OWNER OR AUTHORIZED REPRESENTATIVE

DATE

Depending on the payment option selected, a security deposit may be required. Acceptable types of security deposits include: CASH Funds held by the Board of Equalization. DEPOSITACCOUNTS Automatically renewable accounts and other accounts in federally insured savings institutions located in California earn interest. The original evidence of deposit, such as certificate, passbook, or deposit receipt (when a certificate or passbook is not issued) must be submitted to the Board of Equalization. The account must be in the name of the Board of Equalization or an assignment form must accompany the evidence of deposit. STATEANDFEDERALCREDITUNIONSHARES The California Credit Union League will print and provide the necessary assignment forms. SURETYBONDS Insurers issue bonds as evidence of a surety policy. Approved bond forms with an original signature of the Attorneyin-Fact for the Surety must be submitted. LETTEROFCREDIT A binding irrevocable letter of credit obtained through your bank or financial institution to guarantee payment. Form BOE-487-DCB, Irrevocable Letter of Credit must be submitted for approval by the Board of Equalization. Upon approval of this application, you will be notified in writing of the credit limit and effective start date for your deferred payments. If your election is not approved, you will be notified in writing. Notetosignatory: If you are not a corporate officer, partner, or owner, this signature certifies under penalty of perjury that you hold power of attorney to authorize permission to elect a deferred payment option for purchasing cigarette tax stamps or meter register settings. Mailto: STATE BOARD OF EQUALIZATION Excise Taxes Division MIC:56 Attn: Security Desk PO Box 942879 Sacramento, CA 94279-0056

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