Fillable Printable Form 5301 - Missouri Department Of Revenue
Fillable Printable Form 5301 - Missouri Department Of Revenue
Form 5301 - Missouri Department Of Revenue
Missouri Department of Revenue
Missouri Tobacco Directory
Participating Manufacturer Brands Certification
Form
5301
Company Name
Brand Family Brand Style Container
Select One
Attach To Missouri Tobacco Directory - Participating Manufacturer Certification (Form 5305)
Page of
As of the date of this certification, the manufacturer identified in the Manufacturer Identification section of Form 5305 is a Participating Manufacturer (PM) and has generally performed its financial
obligations under the Master Settlement Agreement (MSA). The PM certifies that the brand families listed in this certification are a complete list of the brand families which are deemed to be its
cigarettes (including RYO product) for purposes of calculating payments under the MSA in the volumes and shares determined pursuant to the MSA. Nothing in this certification shall limit or
otherwise affect the State’s right to maintain that a brand family constitutes cigarettes or RYO tobacco of a different tobacco product manufacturer for the purposes of calculating payment under the MSA.
Asterisk (*) denotes brands that will not be sold in Missouri during the current year.
r Cigarette r RYO
Brand Family Certification
Size Flavor
Packaging
Submitted
(Yes or No)
Fire Safe
(Yes or No)
r Cigarette r RYO
r Cigarette r RYO
r Cigarette r RYO
r Cigarette r RYO
r Cigarette r RYO
r Cigarette r RYO
r Cigarette r RYO
r Cigarette r RYO
r Cigarette r RYO
r Cigarette r RYO
UPC Code
(Pack or Box)
Signature
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Signature of Authorized Person For Participating Manufacturer Printed Name Title Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Form 5301 (Revised 09-2014)
Mail to: Taxation Division and Missouri 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 http://www.dor.mo.gov/business/tobacco/motobacco.php for additional information.
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