INDIANA DEPARTMENT OF REVENUE P.O. BOX 901 ATTN: SPECIAL TAX LICENSING INDIANAPOLIS, IN 46206-0901 CIG - 1A SF 48477 (R2 /10-07) FOR OFFICE USE ONLY CIG *This form must be submitted 30 days prior to: a) the expiration of your current license or, b) the date you begin your business. You may not do business without your certificate. APPLICATION FOR CIGARETTE DISTRIBUTOR’S REGISTRATION CERTIFICATE Renewal New Certificate Applicant’s Name - Enter individual, partnership, or corporation name Federal ID Number Business/Trade Name (if different than above) Telephone Number Mailing Address (Street or P.O. Box Number) City or Town County State Zip Code Physical Address of Business City or Town County State Zip Code Type of Ownership: Sole Proprietorship Partnership Owner’s Social Security # Corporation If Corporation: Date of Incorporation: If Foreign Corporation: Date of Acceptance by Indiana Secretary of State: If an Indiana Corporation or a Foreign Corporation, Give Name and Address of Resident Agent: Identification of Partners or Corporate Officers: Name (last name first) Social Security Number Are You registering to be a STAMPING DISTRIBUTOR? Address City State Yes Does Applicant Presently Hold an OTP License? Yes Number Does Applicant Presently Hold a Cigarette License? Yes Number Has Applicant Previously Held a Cigarette License? Yes Number Does Applicant Presently Hold an Indiana Registered Retail Merchants Certificate? Yes Number Does Applicant Presently Hold Any Other License or Permits Issued by any State Agency? (Please List Below) Yes STATE AGENCY TYPE OF LICENSE OR PERMIT Zip Code Title No No No No No No NUMBER American LegalNet, Inc. www.FormsWorkflow.com Audit Information: Location Where Records Will Be Available For Audit: Phone Number of Location Of Audit Records: Phone Number of Business Location: Indicate Address and Certificate Number of Each Location In Which You Have Cigarettes in Storage Location Cigarette Number From What Source do you intend to buy Cigarettes? _____ A. Direct from Manufacturer _____ B. Wholesaler outside the State of Indiana: Unstamped ________ Stamped________ _____ C. Indiana Distributor: Unstamped ________ Stamped ________ IF YOU INTEND TO PURCHASE CIGARETTES PRESTAMPED FOR RESALE IN INDIANA, YOU MUST PROVIDE THE FOLLOWING INFORMATION FOR AT LEAST TEN CUSTOMERS. RETAILER ADDRESS PHONE NUMBER RETAIL MERCHANTS CERTIFICATE NUMBER 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Does Your Company Expect to Sell Cigarettes Into Another State? Yes _____ No_____ If Yes, List the State(s) and License/Certificate Number(s):__________________________________________ I hereby declare under penalties of perjury that the information contained in this return, including accompanying schedules and statements, is true, correct and complete to the best of my knowledge and belief. Signature of Taxpayer or Agent Title Telephone Number Date American LegalNet, Inc. www.FormsWorkflow.com