Form BOE-400-LWR Fillable Renewal Application for Wholesaler's Cigarette and Tobacco Products License

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Download Form BOE-400-LWR

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$1 000 00 ((describe) ) (10 LIST ALL OF YOUR ADDITIONAL STORAGE LOCATIONS (attach additional page if necessary)) (2 New Corporation/LLC name and number (list names of corporate/LLC officers members or managers below)) (3 NEW OWNER/PARTNER/PRESIDENT NAME) (3 TOTAL AMOUNT DUE AND PAYABLE (multiply line 1 x line 2) $) (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)) (6 NEW MAILING ADDRESS (if different from business location; do not enter agent's address here)) (7 NEW AGENT/BOOKKEEPER NAME) (8 NEW AGENT/BOOKKEEPER TELEPHONE NUMBER (AREA CODE)) (8 NEW AGENT/BOOKKEEPER TELEPHONE NUMBER) (9 NEW AGENT/BOOKKEEPER MAILING ADDRESS) (ACCOUNT NUMBER:) (attach additional page if necessary) (BOE USE ONLY ) (CLEAR) CLEAR (COLUMN A A BUSINESS NAME (must provide if not listed below) ) (COLUMN A A BUSINESS NAME (must provide if not listed below) ) (COLUMN A A BUSINESS NAME (must provide if not listed below) ) (COLUMN A A BUSINESS NAME (must provide if not listed below) ) (COLUMN A A BUSINESS NAME (must provide if not listed below) ) (COLUMN B BUSINESS ADDRESS) (COLUMN B BUSINESS ADDRESS) (COLUMN B BUSINESS ADDRESS) (COLUMN B BUSINESS ADDRESS) (COLUMN B BUSINESS ADDRESS) (COLUMN C TELEPHONE NUMBER (including area code) ) (COLUMN C TELEPHONE NUMBER (including area code) ) (COLUMN C TELEPHONE NUMBER (including area code) ) (COLUMN C TELEPHONE NUMBER (including area code) ) (COLUMN D EMAIL ADDRESS ) (COLUMN D EMAIL ADDRESS ) (COLUMN D EMAIL ADDRESS ) (COLUMN D EMAIL ADDRESS ) (COLUMN D EMAIL ADDRESS ) (COLUMN E ENTER "1" IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (COLUMN E ENTER 1 IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (COLUMN E ENTER 1 IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (COLUMN E ENTER 1 IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (COLUMN E ENTER 1 IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (COLUMN E ENTER 1 IF CIGARETTE OR TOBACCO PRODUCTS WILL BE SOLD AT THIS LOCATION ) (DATE) (DAYTIME TELEPHONE NUMBER (AREA CODE)) (DAYTIME TELEPHONE NUMBER 2 (AREA CODE)) (DAYTIME TELEPHONE NUMBER 2) (DAYTIME TELEPHONE NUMBER) (EMAIL ADDRESS) (I am no longer in business Date business discontinued:) (If you are storing cigarettes and/or tobacco products at a California location other than your sales location please list all storage locations (attach additional page if necessary) ) (OWNER NAME:) (PERIOD:) (Please provide your current daytime telephone number and address:) (PRINT NAME AND TITLE) (PRINT) PRINT (Row 1 ) (Row 10 ) (Row 3 ) (Row 4 ) (Row 5 ) (Row 6 ) (Row 7 ) (Row 8 ) (Row 9 ) (SECTION I: CIGARETTE AND TOBACCO PRODUCTS LICENSE RENEWAL FEE COMPUTATION 1 Enter the total number of business locations for renewal that you operate at which cigarettes or tobacco products are sold (from Schedule A if more than one location) ) (Sticky Note comment 4/15/2013 1:11:59 PM (Sticky Note comment dsoule (TELEPHONE (AREA CODE)) (TELEPHONE NUMBER (AREA CODE)) (TELEPHONE NUMBER) (text) (text) (text) (text) (text) (YOUR ACCOUNT NO ) [ FOID 1 Enter the total number of business locations for renewal that you operate at which 1 PLEASE CHECK TYPE OF NEW OWNERSHIP 10 LIST ALL OF YOUR ADDITIONAL STORAGE LOCATIONS (attach additional page if necessary) 11/10/2011 5:52:24 PM 2 Annual license renewal fee per business location 2 NEW CORPORATION/LLC NAME AND NUMBER (list names of corporate/LLCofficers members or managers below) 3 NEW OWNER/PARTNER/PRESIDENT NAME 3 TOTAL AMOUNT DUE AND PAYABLE (multiply line 1 x line 2) 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) 6 NEW MAILING ADDRESS (if different from business location; do not enter agent's address here) 7 NEW AGENT/BOOKKEEPER NAME 8 NEW AGENT/BOOKKEEPER TELEPHONE NUMBER( ) 9 NEW AGENT/BOOKKEEPER MAILING ADDRESS A (if enclosed) Your renewal application will not be processed if it is incomplete or not signed under Section I and A valid wholesaler account number is required for this application to be processed (Example LW STF 90 1XXXXX) ABUSINESS NAME(must provide if not listed below) ACCOUNT NUMBER: Always write your account number on your check or money order Make a copy of this document for your records 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 attach authorization signed by all general partners; for a corporation attach corporate resolution; and for a LLC attach articles of BBUSINESS ADDRESS BOARD OF EQUALIZATION BOE 400 LWR (S1B) REV 4 (4 13) BOE 400 LWR (S1F) REV 4 (4 13)STATE OF CALIFORNIA BOE 400 LWR (S2) REV 4 (4 13) BOE USE ONLYRA B/AAUDREGRR QSFILEREFEFF Business and Professions Code (If you are unable to affirm this statement you must provide the BOE with a separate statement containing the CALIFORNIA CIGARETTE AND TOBACCO PRODUCTS LICENSING ACT OF 2003 CALIFORNIA CIGARETTE AND TOBACCO PRODUCTS LICENSING ACT OF 2003SCHEDULE A WHOLESALER'S BUSINESS LOCATIONS RENEWAL Cancellation Notice; Section III: Business Change; Section IV: Additional Information; Section V: Signature; and Schedule Check box only if you have completed Section II and/or Section III of this form cigarettes or tobacco products are sold (from Schedule A if more than one location)1 Code (the Act) The Act requires every wholesaler of cigarettes or tobacco products in this state to be licensed by the BOE 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 completed power of attorney form must be attached to this application Corporation CTELEPHONENUMBER(includingarea code) DAYTIME TELEPHONE NUMBER( ) defined in California Business and Professions Code section 22971(p)) pertaining to the manufacture sale or distribution of cigarettes or DEMAIL ADDRESS EENTER 1IF CIGARETTE ORTOBACCO PRODUCTSWILL BE SOLDAT THIS LOCATION EENTER 1IF CIGARETTE ORTOBACCO PRODUCTSWILL BE SOLDAT THIS LOCATION TOTAL NUMBER OF LICENSES REQUIRED: EMAIL ADDRESS Equalization for the amount of the license renewal fee due FILING REQUIREMENTS fine of not more than one thousand dollars ($1 000) or both the fine and imprisonment For an account number please call us at 1 800 400 7115 (TTY:711) and select "Special Taxes and Fees " ) for the account mailing address) GENERAL INFORMATION I affirm that the applicant (including each general partner and each person who has control as defined in California Business and Professions I am no longer in business Date business discontinued: I certify that all the information provided in this application is complete true and accurate I understand that any person who asserts the truth of I hereby certify that this application including any accompanying schedules and statements has beenexamined by me and to the best of my knowledge and belief is a true correct and complete application If you are storing cigarettes and/or tobacco products at a California location other than your sales location please list all storage locations If you are storing cigarettes and/or tobacco products at a California location other than your sales location please refer to If you need additional information please contact the State Board of Equalization Special Taxes and Fees P O Box942879 Sacramento CA 94279 0088 You may visit the BOE website at www boe ca gov or call the Taxpayer Information Section at 1 800 400 7115 (TTY:711); from the main menu select the option Special Taxes and Fees license This application must be postmarked on or before the due date The renewal application consists of page (S1F) Licensing Act of 2003 under Division 8 6 (commencing with section 22970) of the California Business and Professions Limited Liability Company (LLC) Limited Liability Partnership (LLP) Limited Partnership (LP) Make check or money order payable to State Board of Equalization Married Co Partnership MigrationConfirmed set by dsoule) nature of any violation or reasons that will prevent you from complying with the requirements with respect to the statement ) Note: This must be signed by an owner partner corporate officer LLC member or manager or by an authorized agent For a partnership or any rule of the State Board of Equalization applicable to the applicant (including each general partner and each person who has control as organization which authorize the individual who signs below to certify this application If signed by an authorized agent a properly Other (describe) our website at www boe ca gov click on eServices tab and log in to make a payment To pay by credit card go to our OWNER NAME: Partnership Payments You can make your payment by paper check Online ACH Debit (ePay) or by credit card To use ePay go to PERIOD: Please provide your current daytime telephone number and address: Please use this address as my mailing address (check box and attach signed power of attorney form to use agent address PO BOX 942879 PRINT NAME AND TITLE products Products License) Professions Code section 22971(p)) also agrees to comply with the reporting payment recordkeeping and license display requirements as READ INSTRUCTIONSBEFORE PREPARING Registered Domestic Partnership RENEWAL APPLICATION FOR WHOLESALER'S CIGARETTE AND SACRAMENTO CA 94279 0088 SECTION I: CIGARETTE AND TOBACCO PRODUCTS LICENSE RENEWAL FEE COMPUTATION Section I: Cigarette and Tobacco Products License Renewal Fee Computation; page (S1B) which includes Section II: SECTION II: CANCELLATION NOTICE(complete this section if you will not be renewing your Wholesaler's Cigarette and Tobacco SECTION III: BUSINESS CHANGE(complete this section only if the information preprinted on the front of this application oron the enclosed Schedule A if applicable is incorrect or if there has been a change in the ownership of the business) Section IV on the second page SECTION IV: ADDITIONAL INFORMATION Section V The completed renewal application must be accompanied by a remittance payable to the State Board of SECTION V: SIGNATURE(this section must be completed if you made changes to Section II or III) SIGNATUREEMAIL ADDRESS SIGNATUREPRINT NAME AND TITLE Sole Owner SPECIAL TAXES AND FEES specified in the Cigarette and Tobacco Products Licensing Act of 2003 under Division 8 6 (commencing with section 22970) of the California STATE OF CALIFORNIABOARD OF EQUALIZATION STORAGE LOCATIONS TELEPHONE( ) The State Board of Equalization (BOE) is responsible for administering the California Cigarette and Tobacco Products TOBACCO PRODUCTS LICENSE tobacco products The applicant (including each general partner and each person who has control as defined in California Business and Under the Act every wholesaler must annually obtain and maintain a license to engage in the sale of cigarettes or tobacco 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 website or call 1 855 292 8931 Be sure to sign and mail your application Without an account number the issuance of your license may take several weeks You must complete and return this application to the BOE in order to maintain your cigarette and tobacco products YOUR ACCOUNT NO

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