(ADDRESS)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(CIGARETTE MANUFACTURER/IMPORTER NAME)
(CLEAR) CLEAR
(DATE)
(EMAIL ADDRESS)
(NAME OF AUTHORIZED AGENT (typed or printed))
(PRINT) PRINT
(TELEPHONE NUMBER)
(TITLE)
94279 0088 If more space is required you may copy this form
ADDRESS
As required by the California Cigarette and Tobacco Products Licensing Act of 2003 (California Business and Professions Code
BOARD OF EQUALIZATION
BOE 400 LMI2 REV 5 (5 12)
brand is manufactured or imported by the reporting company or a listed brand is no longer manufactured or imported by the
BRAND NAME BRAND NAME
CIGARETTE MANUFACTURER/IMPORTER NAME
Complete this schedule and mail it to the Board of Equalization Special Taxes and Fees P O Box 942879 Sacramento CA
eligible for obtaining and maintaining a license a manufacturer or importer must submit to the Board of Equalization (BOE) a list
EMAIL ADDRESS
Information Section at 800 400 7115 (TTY:711)
NAME OF AUTHORIZED AGENT (typed or printed)
of all brand families that it manufactures or imports
Pursuant to Chapter 4 of the California Business and Professions Code (commencing with section 22979) in order to be
reporting company To obtain additional copies of this form please visit our website at www boe ca gov or call our Taxpayer
SCHEDULE OF CIGARETTE BRAND FAMILY NAMES
section 22979) the reporting company must update the schedule and provide a copy to the BOE whenever a new or additional
SIGNATURE OF AUTHORIZED AGENT
STATE OF CALIFORNIA
TELEPHONE NUMBER
TITLE
