Fillable Printable Form 5300 - Missouri Department Of Revenue

Form 5300 - Missouri Department Of Revenue

Form 5300 (Revised 01-2015)

Form

5300

Missouri Department of Revenue

Non-Participating Manufacturer’s (NPM) Appointment

of Registered Agent For The State Of Missouri

Non-Participating

Tobacco Manufacturers

The undersigned Non-Participating Manufacturer (NPM) _____________________________________________________

hereby appoints and authorizes _________________________________________________________________________

as its registered agent to receive service of process on our behalf. The undersigned NPM agrees to provide notice to the

Director of Revenue, at least 30 days prior to termination of the authority of the registered agent, and to provide

proof to the satisfaction of the Director of Revenue of the appointment of a new agent at least five calendar days prior to the

termination of an existing agent agreement.

Under penalty of perjury, I certify and declare that all of the statements and information contained in this Certification,

including but not limited to any accompanying statements or attachments herewith, are true, accurate and complete

in every particular and that I am a person authorized to bind the NPM making the Certification either under the laws of

the state of Missouri or of the jurisdiction where the manufacturer resides or is organized. Any violation of the

requirements of Section 196.1026, RSMo, is a basis for removal of the applicant’s brand families from Missouri’s Directory of

Compliant Tobacco Products Manufacturers. Brand families that are not listed on Missouri’s Directory of Compliant Tobacco

Products Manufacturers are not eligible to be sold in the state of Missouri.

Signature

Signature Of Authorized Person For Non-Participating Manufacturer Title

Authorized Person Printed Name Date Signed (MM/DD/YYYY)

Principal Place of Business (Physical Address)

City State ZIP Code

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.

__ __ /__ __ /__ __ __ __

Mail to:Taxation Division andMissouri Attorney General Phone: (573) 751-7163

P.O. Box 811 P.O. Box 899 Fax: (573) 522-1720

Jefferson City, MO 65105-0811 Jefferson City, MO 65102-0899 TTY: (800) 735-2966

Visit //dor.mo.gov/business/tobacco/motobacco.php for additional information.