BOE-400-LDR (S1F) REV. 1 (6-07)
STATE OF CALIFORNIA
RENEWAL APPLICATION FOR DISTRIBUTOR'S CIGARETTE AND TOBACCO PRODUCTS 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 distributor of cigarettes or tobacco products in this state to be licensed by the Board. Under the Act, every distributor must annually obtain and maintain a license to engage in the sale of cigarettes or tobacco products. FILING REQUIREMENTS You must complete and return this application to the Board in order to maintain your cigarette and tobacco products license. This application must be postmarked on or before the due date. The renewal application consists of page (S1F) Section I: Cigarette and Tobacco Products License Renewal Fee Computation; page (S1B) which includes Section II: Cancellation Notice; Section III: Business Change; Section IV: Signature; and Schedule A, (if enclosed). Your renewal application will not be processed if it is incomplete or not signed under Section I and Section IV. The completed renewal application must be accompanied by a remittance payable to the State Board of Equalization for the amount of the license renewal fee due.
Credit Card Payments. You can use a Discover/Novus, MasterCard, VISA, or American Express credit card to pay the amount due. Other credit cards cannot be accepted. EFT accounts are not eligible for credit card payments. Credit card payments can be made by calling 800-272-9829 or through our website at www.boe.ca.gov. After authorizing your payment, check the box below indicating you have paid with a credit card. Be sure to sign and mail your return.
SECTION I: CIGARETTE AND TOBACCO PRODUCTS LICENSE RENEWAL FEE COMPUTATION 1. Enter the total number of business locations for which you are applying for renewal that you operate at which cigarettes or tobacco products are sold (from Schedule A if more than one location) 2. Annual license renewal fee per business location 3. TOTAL AMOUNT DUE AND PAYABLE (multiply line 1 x line 2) Check box only if you have completed Section II and/or Section III of this form.
IF PAID BY CREDIT CARD, CHECK HERE (Mandatory EFT accounts MUST pay by EFT). [ ]
1. 2. $1,000.00 3.
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 E-MAIL ADDRESS TELEPHONE NUMBER DATE
Make check or money order payable to State Board of Equalization. Always write your account number on your check or money order. Make a copy of this document for your records. (continued on reverse)
BOE-400-LDR (S1B) REV. 1 (6-07)
SECTION II: CANCELLATION NOTICE (complete this section if you will not be renewing your Distributor's Cigarette and Tobacco Products License) I am no longer in business. Date business discontinued: Please provide your current daytime telephone number and address: SECTION III: BUSINESS CHANGE (complete this section only if the information preprinted on the front of this application or on the enclosed Schedule A, if applicable, is incorrect or if there has been a change in the ownership of the business)
1) TYPE OF NEW OWNERSHIP
Sole Proprietor Corporation
Husband & Wife Co-Partnership Limited Liability Company (LLC)
Limited Partnership (LP)
Limited Liability Partnership (LLP) Other (describe) ________________
Registered Domestic Partnership
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 I affirm that the applicant (including each general partner and each person who has control as defined in California Business and Professions Code section 22971(p)) has not been convicted of a felony under sections 30473 or 30480 of the Revenue and Taxation Code and has not violated and will not violate or cause or permit to be violated any of the provisions of the Cigarette and Tobacco Products Licensing Act of 2003 or any rule of the State Board of Equalization applicable to the applicant (including each general partner and each person who has control as defined in California Business and Professions Code section 22971(p)) pertaining to the manufacture, sale, or distribution of cigarettes or tobacco products. The applicant (including each general partner and each person who has control as defined in California Business and Professions Code section 22971(p)) also agrees to comply with the reporting, payment, recordkeeping, and license display requirements as specified in the Cigarette and Tobacco Products Licensing Act of 2003 under Division 8.6 (commencing with section 22970) of the California Business and Professions Code. (If you are unable to affirm this statement, you must provide the Board with a separate statement containing the nature of any violation or reasons that will prevent you from complying with the requirements with respect to the statement.) I certify that all the information provided in this application is complete, 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 county jail, or a fine of not more than one thousand dollars ($1,000), or both the fine and imprisonment. Note: This must be signed by an owner, partner, corporate officer, LLC member or manager, or by an authorized agent. For a partnership, attach authorization signed by all general partners; for a corporation, attach corporate resolution; and for a LLC, attach articles of organization which authorize the individual who signs below to certify this application. If signed by an authorized agent, a properly completed power of attorney form must be attached to this application.
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
BOE-400-LDR (S2) REV. 1 (6-07)
STATE OF CALIFORNIA
CALIFORNIA CIGARETTE AND TOBACCO PRODUCTS LICENSING ACT OF 2003 SCHEDULE A - DISTRIBUTOR'S BUSINESS LOCATIONS RENEWAL
ACCOUNT NUMBER: A BUSINESS NAME (must provide if not listed below) OWNER NAME: B BUSINESS ADDRESS C TELEPHONE NUMBER (including area code) PERIOD: D E-MAIL ADDRESS
BOARD OF EQUALIZATION
E ENTER 1 IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION
TOTAL NUMBER OF LICENSES REQUIRED: