Free Form CG-80 - New York

For office use only
New York State Department of Taxation and Finance

CG-80
(11/04)

Application for Registration as a Chain Store
Pursuant to Tax Law Article 20-A, Cigarette Marketing Standards Act

A chain store registration is granted exclusively to the applicant and is not transferable.
Read Form CG-80-I, Instructions for Form CG-80, carefully before completing this application. Attach additional sheets as necessary to fully answer all questions. Once registration is granted, the certificate of chain store registration must be publicly displayed at your place of business (other than individual vending machines). Keep a copy for your records. Mark an X in the appropriate box for this application. (For definitions and information required to be submitted with this form, see Definitions and
Documentation requirements on Form CG-80-I.)

Cooperative member ....................................................................................................................................................
Name of cooperative FEIN of cooperative

Registration fee $300*

Franchisee ....................................................................................................................................................................
Name of franchisor FEIN of franchisor

$300*

Vending machine operator (must have 15 or more marketing locations within NYS) ...................................................
NYS wholesale dealer license number

$250*

CWV ­
Large volume outlet operator (one fee based per operator, not per outlet) ................................................................. Business with 15 or more retail outlets ...................................................................................................................... Currently licensed (reporting additional registered locations or vending machines) ..................................................... *If the registration fee has been paid within the preceding 12 months, the registration fee is $200. Print or type
1. Legal name

$300* $300* No fee

2. Trade name/dba (if different from above)

3. Address of principal place of business (number and street; see instructions)

City

State

ZIP code

4. County (principal place of business)

5. Telephone number of principal place of business

6. Date business began or 7. FEIN will begin in New York State

8. Other FEIN, if any

(

)
Sole proprietor Other (specify):

/

/
Partnership Corporation

9. Type of organization (mark an X in one or more boxes)

10. Mailing address (if different from business address)

City

State

ZIP code

Page 2 of 4 CG-80 (11/04) 11. Mark an X in the appropriate box to indicate whether your business is currently registered or has tax accounts with New York State for the following taxes: A. B. C. D. E. Cigarette tax/tobacco products tax (Article 20) ...................... Sales tax (must be registered; see page 4) ................................. Corporation tax ....................................................................... Withholding tax ....................................................................... Other taxes (specify below) ...................................................... Specify type(s) of taxes: Yes Yes Yes Yes Yes No No No No No If Yes, enter identification number below.

12. List officers, directors, and certain shareholders, partners, or sole proprietor. (See instructions; attach additional sheets if necessary.)
Name Home address (number and street) City Name Home address (number and street) City Name Home address (number and street) City Name Home address (number and street) City State ZIP code State ZIP code State ZIP code State ZIP code Social security number Title Telephone number Percent of ownership

(

)
Percent of ownership

Social security number Title Telephone number

(

)
Percent of ownership

Social security number Title Telephone number

(

)
Percent of ownership

Social security number Title Telephone number

(

)
%

13. Enter the percentage of voting stock held by all other owners. (The total percentage of voting stock in items 12 and 13 must equal 100%) ................................................................................................................................................................... 14. During the last 5 years, has the applicant or any person listed in item 12: -- owned or controlled, directly or indirectly, more than 10% of the shares of stock (25% or more if four or fewer shareholders own or control voting stock of such business) entitling the holder to vote for directors or trustees of a business other than the applicant, or -- been an officer, director, or partner of a business other than the applicant's business? ................................................ Yes If Yes, complete below. Attach additional sheets if necessary.
Name of other business Address (number and street) Name of person or applicant Name of other business Address (number and street) Name of person or applicant Name of other business Address (number and street) Name of person or applicant City State FEIN ZIP code City State FEIN ZIP code City State FEIN ZIP code

No

CG-80 (11/04) Page 3 of 4 15. Does the applicant, anyone listed in item 12, or any business listed in item 14 (at the time anyone listed in item 12 was so connected with the business) have any outstanding liability for New York State tax, New York City income or nonresident earnings tax, or city of Yonkers surcharge or nonresident earnings tax? ....... If Yes, complete below. Attach additional sheets if necessary. Name of applicant, person, or business Type of tax Amount due Assessment number Assessment date

Yes

No

/ / / / / / /
16. In the past five years, was the applicant, anyone listed in item 12, or any business listed in item 14 (at the time anyone listed in item 12 was so connected with the business) convicted of any crimes? (see instructions) ............ If Yes, complete below. Attach additional sheets if necessary.
Name of applicant, person, or business Date of conviction Court of conviction City and state of arrest Statute section convicted of violating Disposition (fine, imprisonment, etc.)

/ / / / / / /

Yes

No

/

/

Detailed description of charges

17. In the past five years, has the applicant, anyone listed in item 12, or any business listed in item 14 (while anyone listed in item 12 was so connected with that business) had a license as a cigarette wholesale dealer or agent or a registration as a chain store canceled suspended, or denied? ........................................................................... If Yes, complete below. Attach additional sheets if necessary. Name of applicant, person, or business

Yes

No

Date and detailed reason for cancellation/suspension/denial

18. Has the applicant, any person listed in item 12, or any business listed in item 14 (at the time anyone listed in item 12 was so connected with that business) been finally determined to have violated any provision of Article 20 (Cigarette Tax) or Article 20-A (Cigarette Marketing Standards Act), or any rule or regulation adopted pursuant to Tax Law Articles 20 or 20-A? ..................................................................................................... If Yes, complete below. Attach additional sheets if necessary.
Name of applicant, person, or business Statute section, rule or regulation section violated Detailed description of violation

Yes

No

Date of violation

/

/

Disposition (fine, imprisonment, etc.)

Page 4 of 4 CG-80 (11/04) 19. List all current or anticipated cigarette suppliers. Attach additional sheets if necessary.

Name of supplier
Street Street Street

Address of supplier
City City City State State State ZIP Code ZIP Code ZIP Code

20. If you are applying as a cooperative member, did you purchase from the cooperative in the preceding 3 months at least 25% of all merchandise purchased for resale (excluding cigarettes and petroleum products)? The calculation of the percentage is based on price paid ........................................................................ 21. If you are applying as a cooperative member, do you share in the profits and losses of the cooperative? ................... 22. If you are applying as a large volume outlet operator, did one or more of your retail outlets through which cigarettes are sold in New York State have gross sales (excluding petroleum products) of more than $2,000,000 in the preceding calendar year? ......................................................................... Note: This application for registration as a chain store will not be approved until all of the following conditions are met:

Yes Yes

No No

Yes

No

-- You are registered as a sales tax vendor. Include a copy of the sales tax Certificate of Authority for each outlet. If you are not so registered, submit Form DTF-17, Application for Registration as a Sales Tax Vendor (see Need help? on Form CG-80-I). -- You and all persons listed in item 12 have satisfied all outstanding tax liabilities and have filed all appropriate tax returns. -- You have submitted the required documentation for the type of business under which you are registering as a chain store (see instructions). -- You have registered each location and each vending machine. If not, submit Form DTF-716, Application for Registration of Retail Dealers and Vending Machines for Sales of Cigarettes and Tobacco Products. -- You are licensed as a wholesale dealer if you own, operate, or maintain one or more cigarette vending machines in, at, or upon premises owned or occupied by another person. If you are not licensed as a wholesaler dealer but should be, submit Form CG-100-V, Application for License as a Wholesale Cigarette Dealer Who Only Operates Vending Machines. -- The application is signed and dated by an officer, director, shareholder, partner, or the sole proprietor listed in item 12 of this application. -- A bank check, certified check, money order, or other draft acceptable to the department for the applicable registration fee, made payable to, Commissioner of Taxation and Finance, is submitted with the application. Mail all documents to:
NYS TAX DEPARTMENT TTTB FACCTS - REGISTRATION AND BONDING UNIT BUILDING 8 W A HARRIMAN CAMPUS ALBANY NY 12227

Warning
The Department of Taxation and Finance has the right to suspend or revoke a registration as a chain store for violation of the provisions of Tax Law Article 20 (Cigarette Tax Law) or Tax Law Article 20-A (Cigarette Marketing Standards Act). It is a Class B misdemeanor for a chain store to induce or attempt to induce, or to procure or attempt to procure, the purchase of cigarettes at a price less than the cost of the agent or wholesaler with respect to sales to chain stores. It is also a Class B misdemeanor for a chain store to induce or attempt to induce, or to procure or attempt to procure, any rebate or concession of any kind in connection with the purchase of cigarettes. Making a false or misleading statement on this application will be viewed by the department as an attempt to procure cigarettes below the minimum price and will result in the revocation or your registration as a chain store. In addition, the department may forbid you from subsequently selling cigarettes at retail. Certification -- I certify that the information herein provided is true and correct to the best of my knowledge, and that the applicant herein named is qualified under the Cigarette Marketing Standards Act to be a chain store.
Name (print) Signature Title Date