Free Form CG-100-W - New York

New York State Department of Taxation and Finance

Application for License as a Wholesale Cigarette Dealer Other Than Those Who Only Operate Vending Machines
Article 20 of the Tax Law
Send completed application and all required documentation to:
NEW YORK STATE TAX DEPARTMENT TTTB - REGISTRATION AND BOND UNIT WA HARRIMAN CAMPUS -- 855 ALBANY NY 12227

CG-100-W
(1/02)
For office use only

Read the instructions carefully before completing this application. Attach additional sheets as necessary to fully answer all questions. Unanswered questions will delay the processing of this application. Reason for application (refer to instructions) : New applicant 1. Print or type (a) Legal name Currently licensed and adding location(s) Relicensing Transfer of license

(b) (c)

Trade name (if different from item a) Cigarette related activities you are currently or will be involved in (check all applicable boxes)

Manufacturer

Importer

Retailer Other

Wholesaler

Exporter

Vending Machine Operator

(d) Names and addresses of all of your cigarette suppliers: Name

Street address, city, and state

2.

Street address of all storage locations

Mailing address

City, town or village, state, ZIP code

Telephone number

City, town or village, state, ZIP code

(

)

Between what streets or avenues. (If outside city limits and not known by a house number, specify location in relation to nearest intersecting road or highway.)

State the specific location in the building where your business is to be conducted.

3. (a) Type of organization (check only one box) Individual Partnership LLC Corporation LLP Other (specify)

(b) Federal employer identification number (FEIN) (c) Other FEIN(s), if any

(d) Date business began or will begin in New York State

Attach additional sheets as needed. Please include the item number referenced on additional sheets.

Page 2 of 8 CG-100-W (1/02) 4. (a) Do you own or lease the premises listed in item 2 above? If owned, you must provide a copy of the deed, and proceed to item 5. (b) If leased, state name and address of the immediate lessor, the date of the lease and the date of expiration thereof. Enclose a copy of the lease. (c) Do the terms of such lease require payment by the applicant of any consideration based on a percentage of the receipts of the business? (d) If Yes, state percentage and give details. 4. (a)

Own

Lease (attach copy of lease and Form CG-100-L)
Date of lease Date of expiration

(b) Name and address of the immediate lessor

(c)

Yes

No

(d) Percentage and details

(e) If location is not owned by applicant, does anyone required to be listed in items 6 or 7 have an ownership interest in the premises? 5. (a) Will the applicant retail any cigarettes at the location listed in item 2? (b) If Yes, indicate the percentage to be sold at retail. (c) Are there any retail sales of cigarettes at any other locations operated by applicant? (d) Does the applicant and/or controlling person as defined in item 20 have any interest in any other business located in the same building? (e) If Yes, explain interest, relationship, type of products, and/or services sold.

If Yes, please give name (e)

Yes

No

5.

(a)

Yes

No

(b) Retail %

(c)

Yes

No

(d)

Yes

No

(e) Details

6. TO BE COMPLETED ONLY BY INDIVIDUAL OR PARTNERSHIP APPLICANTS, INCLUDING LLP'S AND LLC'S TREATED AS PARTNERSHIPS BY THE IRS.
Name, Social Security Number (SSN) and date of birth (DOB) of sole applicant or partners of partnership Name SSN DOB Name SSN DOB Name SSN DOB Home address Citizenship (name of country) Duties (circle all that apply) Home phone number Area code ( )

ABCDEFG Other

ABCDEFG Other

Area code (

)

ABCDEFG Other

Area code (

)

Attach additional sheets as needed. Please include the item number referenced on additional sheets.

CG-100-W (1/02) Page 3 of 8 7. (a) TO BE COMPLETED ONLY BY CORPORATE APPLICANTS, INCLUDING LLP'S AND LLC'S TREATED AS CORPORATIONS BY THE IRS. State (country) of incorporation: Date of organization: (If applicant is not a New York State corporation, please refer to instructions for additional requirements.) (b) Address of corporate headquarters: Street: City, State, ZIP: Country: List the owner(s) of the applicant. List all shareholders who own or control, directly or indirectly, more than 10% of its voting stock. If any person is not a natural person, refer to instructions.
Home address Percent of stock When Citizenship Duties acquired (name of country) (circle all that apply) common preferred ABCDEFG Other Home phone number )

(c)

Name, SSN and date of birth (DOB) of shareholder(s) Name SSN DOB Name SSN DOB Name SSN DOB

common Area code ( preferred

ABCDEFG Other

common Area code ( preferred

)

ABCDEFG Other

common Area code ( preferred

)

(d)

Enter the total percent of voting shares held by persons not listed in item 7(c). Enter the percentage of ownership held directly or indirectly by the largest shareholder in the group. Enter the total number of shareholders, excluding those listed in item 7(c).

Common

%

Preferred

%

Common Common

%

Preferred Preferred

%

(e)

The names, SSNs, and home addresses of all officers of the corporation as of the date of filing of this application are as follows:
Home address Title of officer Citizenship Duties (name of country) (circle all that apply) Home phone number Area code ( )

Name, SSN and date of birth (DOB) of officer(s) Name SSN DOB Name SSN DOB Name SSN DOB

ABCDEFG Other

ABCDEFG Other

Area code (

)

ABCDEFG Other

Area code (

)

Attach additional sheets as needed. Please include the item number referenced on additional sheets.

Page 4 of 8 CG-100-W (1/02) (f) The names, SSN's, and home addresses of all directors of the corporation as of the date of filing of this application are as follows:
Name, SSN and date of birth (DOB) of director(s) Name SSN DOB Name SSN DOB Name SSN DOB Home address Citizenship (name of country) Duties (circle all that apply) Home phone number Area code ( )

ABCDEFG Other

ABCDEFG Other

Area code (

)

ABCDEFG Other

Area code (

)

8.

(a) Has the applicant or any controlling person as defined in item 20 ever been convicted (including pleas of guilty or no contest) of any felony or of any other crime or offense of any kind except violations of the Vehicle and Traffic Law? (b) If Yes, state date of conviction, crime or offense involved, and name of person convicted. In each case a Certificate of Disposition or a Certificate of Conviction from the court clerk must be attached.

8.

(a)

Yes

No

(b) Date, crime or offense, and name of person convicted

9.

(a) Are there any arrests, indictments, or summonses (except for violations of the Vehicle and Traffic Law) pending against the applicant or any controlling person as defined in item 20? (b) If Yes, state date thereof, crime or offense charged, name of each defendant and jurisdiction.

9.

(a)

Yes

No

(b) Date, crime or offense, name of defendant and jurisdiction

10. (a) Was any application for a license or permit under the cigarette laws of this state or country, or of any other state or country, ever made by the applicant, applicant's spouse, or controlling person as defined in item 20? (b) If Yes, state name of such applicant, address of premises, date of filing of application, and disposition thereof. Give license number if license or permit was issued.

10. (a)

Yes

No

(b) Name of applicant

Address of premises (street, city, town or village, state, or country)

Date filed, disposition, and license number, if any

(c) Has such license or permit ever been denied, revoked, cancelled, suspended, or otherwise involuntarily terminated or surrendered in lieu of cancellation, or has any other penalty been imposed in connection therewith at any time? (d) If Yes, state what action was taken, and date thereof.

(c)

Yes

No

(d) Action and date

Attach additional sheets as needed. Please include the item number referenced on additional sheets.

CG-100-W (1/02) Page 5 of 8 11. (a) Does any person, other than the applicant or a controlling person listed in items 6 or 7: - have any interest (financial, proprietary or other, direct or indirect) in the business to be licensed; - have any loans or advances outstanding to or from the applicant; have any lien or mortgage on the fixtures of the applicant's business? 11. (a)

Yes (Provide full details of the interest, loan, or lien at 11(b)) No

(b) Name and FEIN or SSN

(b) If you answered Yes to 11(a), provide a complete description of the interest, loan or lien, including name, address, and SSN, or FEIN of the person involved.

Address

Nature of interest

Date acquired

12. (a) Will any person, other than the applicant or a controlling person listed in items 6 and 7, share in any way the receipts, 12. (a) profits, losses, or deficiencies of the business (other than as a salesperson receiving commissions at a level customary for the industry)? (b) If you answered Yes to 12(a), provide a complete description of the sharing agreement. See instructions for information that must be included.

Yes (Provide full details of the sharing agreement at 12(b)) No

(b) Name and FEIN or SSN Address Details - see instructions

13. (a) Does the applicant, or any controlling person listed in items 6 and 7, have any interest, direct or indirect, in any other 13. (a) Yes (Provide full details of the interest at 13(b)) business or premises where cigarettes or tobacco products are manufactured, stocked or sold? For this question, No interest includes ownership or other beneficial interest; debtor or creditor relationship; ownership of a security (b) Name and FEIN of business interest in any assets employed in such business; or role as a director in such business. However, interests held in the form of publicly traded securities need not be considered. Address (b) If you answered Yes to 13(a), provide a complete description of the interest, including the name of the applicant or controlling person involved and the name, address and federal identification number of the business. Type of business

Nature of interest

Date acquired

Attach additional sheets as needed. Please include the item number referenced on additional sheets.

Page 6 of 8 CG-100-W (1/02) 14. (a) Has the applicant or any controlling person as defined in item 20 ever been known by any other name or names (including maiden name)? (b) If Yes, state current and former name or names, aliases, dba's, etc., social security numbers, and the reason for change. 14. (a)

Yes

No

(b) Current name and SSN

Former name(s) and SSN

Reason(s) for change:

Current name and SSN

Former name(s) and SSN

Reason(s) for change:

15. (a) Does anyone, other than the applicant, licensed under Article 20 or 20A of the Tax Law occupy any portion of the premises listed in item 2? (b) If Yes, state full name of licensee and license number. If purchasing a business, you must submit a copy of the contract of sale.

15. (a)

Yes

No

(b) Name of licensee

License number

16. Does the applicant have current registrations or tax accounts with New York State for the following taxes? (a) Cigarette tax If Yes, enter identification number Agent Wholesaler Cigarette retailer (b) Corporation tax If Yes, enter identification number (c) Withholding tax If Yes, enter identification number Yes No Yes No Yes No (d) Sales tax Yes No

If Yes, enter identification number If No, include Form DTF-17, Application for Registration as a Sales Tax Vendor

(e) Other taxes

Yes

No

If Yes, enter identification number and type of tax
ID number Type of tax

Attach additional sheets as needed. Please include the item number referenced on additional sheets.

CG-100-W (1/02) Page 7 of 8 17. List applicant's license or certificate numbers issued by the City of New York for the following, if applicable:
City of New York Cigarette agent Wholesale cigarette dealer Retail cigarette dealer License or certificate number

Not applicable
Date issued

Has a City of New York cigarette license or agent's Certificate of Authority ever been surrendered, cancelled, or expired? If Yes, explain:

Yes

No

18. Does the applicant, or any person required to be listed in item 6 or 7, have a liability for any tax imposed by or pursuant to the authority of the NYS Tax Law, or for the City of New York or for the City of Yonkers earnings tax on nonresidents, that has been finally determined Yes (complete below) No to be due and has not been paid in full?
Person's name Type of tax Amount due Assessment number Assessment date

19. List all bank accounts of the applicant:
Bank name Address Account number Type

20. For purposes of the application, the term controlling person means any person who is an officer, director, or partner (or in the case of limited liability company, an officer, member or a person having with respect to such limited liability company authority analogous to that of an officer or director with respect to a corporation) of an applicant for an agent's or a wholesale dealer's license under Article 20 of the Tax Law, or if the applicant is a corporation, a shareholder, directly or indirectly, owning more than 10% of the number of shares of voting stock of such corporation. It also includes persons who do or will exercise authority within the business comparable to the authority normally exercised by corporate officers, regardless of the form of business organization or lack of actual title.

Attach additional sheets as needed. Please include the item number referenced on additional sheets.

Page 8 of 8 CG-100-W (1/02)

Warning
The Department of Taxation and Finance has the right to suspend or revoke a license to be a wholesaler for violation of the provisions of Article 20 of the Tax Law (Cigarette Tax) or Article 20-A of the Tax Law (Cigarette Marketing Standards Act.) Making a false or misleading statement on this application may result in a denial or revocation of your license(s).

THIS CERTIFICATION MUST BE SIGNED AND DATED BY THE INDIVIDUAL APPLICANT AND EACH MEMBER OF A PARTNERSHIP AND A MEMBER OF AN LLP OR LLC TREATED AS A PARTNERSHIP BY THE IRS
The undersigned, each for himself/herself, certifies that he/she is the applicant named above; that he/she knows the contents of the above application and the statements contained therein and the same are true, of his/her own knowledge.

Print name

Title

Signature

Date

THIS CERTIFICATION MUST BE SIGNED AND DATED FOR A CORPORATION OR AN LLP OR LLC TREATED AS A CORPORATION BY THE IRS
certifies that he/she is
(Print name) (Title)

of the above named applicant; that he/she knows the contents of the above application and the statements and answers therein; that the same are true of his/ her own knowledge; that he/she has been authorized, by said applicant, to make the statements and answers in this application on behalf of said applicant.

Date
(Signature of authorized officer)

Privacy Notification
The Commissioner of Taxation and Finance may collect and maintain personal information pursuant to the New York State Tax Law, including but not limited to, sections 171, 171-a, 287, 308, 429, 475, 505, 697, 1096, 1142, and 1415 of that Law; and may require disclosure of social security numbers pursuant to 42 USC 405(c)(2)(C)(i). This information will be used to determine and administer tax liabilities and, when authorized by law, for certain tax offset and exchange of tax information programs as well as for any other lawful purpose. Information concerning quarterly wages paid to employees is provided to certain state agencies for purposes of fraud prevention, support enforcement, evaluation of the effectiveness of certain employment and training programs and other purposes authorized by law. Failure to provide the required information may subject you to civil or criminal penalties, or both, under the Tax Law. This information is maintained by the Director of the Registration and Data Services Bureau, NYS Tax Department, Building 8, Room 338, W A Harriman Campus, Albany NY 12227; telephone 1 800 225-5829. From areas outside the United States and Canada, call (518) 485-6800.

Attach additional sheets as needed. Please include the item number referenced on additional sheets.