Fill - Free fillable Certication of Tobacco Product Manufacturer That Has Not (State of West Virginia) PDF form

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State of WeSt Virginia

Certication of Tobacco Product Manufacturer

That Has Not Signed Master Settlement Agreement

(Pursuant to WV Code §16-9D-3)

Due by April 30 of Reporting Year

Part 1: Tobacco Product Manufacturer Identication

Company Name:

Street Address:

City:

State/Country:

Postal Code:

Telephone:

Fax Number:

E-mail:

Name and Title of Person

Completing Report:

Part 2A: Brand Family Identication of Nonparticipating Manufacturers

The Nonparticipating Manufacturer identied in Part 1 has the following Brand Families, each of which the

manufacturer afrms are to be considered Cigarettes for purposes of WV Code §16-9B-3(b). Add additional pages as

necessary.

Brand Family

Units Sold

in WV in

preceding

calendar

year

Units Sold

in WV in

current

calendar

year thru

May 31

Name and address of other manufacturers

of Brand Family in the preceding or current

calendar year

Indicate with an asterisk (*) any Brand Family sold in the State during the preceding calendar year that is no longer

being sold in the State as of the date of the Certication. Withdrawals must comply with WV Code §16-9B-3(b)(2).

Verication of compliance must be attached.

Part 2B: Brand Names/Manufacturing Locations of Cigarettes not included in Part 2A —

List the brand name and manufacturing locations for any cigarettes that are not included in Part 2A.

Brand Name Manufacturing Location

Reset Form

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Part 3: Nonparticipating Manufacturer Certication.

A. Domicile (check appropriate box)

The Nonparticipating Manufacturer identied in Part 1 is domiciled in the State of West Virginia.

The Nonparticipating Manufacturer identied in Part 1 is a non-resident or foreign Nonparticipating

Manufacturer that has registered with the West Virginia Secretary of State to do business in the State of

West Virginia as a foreign corporation or business entity.

The Nonparticipating Manufacturer identied in Part 1 has appointed a resident for service of process pursuant

to WV Code Section 16-9D-5 on whom all process, and any action or proceeding arising out of enforcement of

Code section 16-9B-1 et seq., and section 16-9D-1 et. seq. may be served in any manner authorized by law.

B. Registered Agent for service of process

The Nonparticipating Manufacturer identied in Part 1 has appointed and continues to engage the following Resident

Agent for Service of Process on whom all process, and any action or proceeding against it concerning or arising out of

the enforcement of WV Code articles 16-9D and 16-9B, may be served in any manner authorized by law:

a g e n t f o r n o n - P a r t i c i P a t i n g M a n u f a c t u r e r

Agent Name:

Company:

Address:

City:

State/Country:

Postal Code:

Phone:

FAX:

E-mail:

PLEASE ATTACH PROOF OF THE APPOINTMENT AND AVAILABILITY OF THE AGENT.

C. Qualied Escrow Fund – Financial Institution

e S c r o W f u n d – f i n a n c i a l i n S t i t u t i o n i n f o r M a t i o n

Name of Institution:

Street Address:

City:

State/Country:

Postal Code:

Escrow Account No.:

State sub-account No.:

FAX:

E-mail:

PLEASE ATTACH AN EXECUTED COPY OF THE NON-PARTICIPATION MANUFACTURING’S ESCROW

AGREEMENT.

Was this Escrow Agreement previously provided to the Attorney General of this State? Yes No

Was it rejected? Yes Rejection Date: ________________________ No

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D. Escrow Deposit/Withdrawal History for West Virginia (attach additional sheets if necessary).

d a t e d e P o S i t W i t h d r a W a l B a l a n c e

Total: Total: Total:

PLEASE ATTACH COPIES OF RECORDS OF THE FINANCIAL INSTITUTION

CONFIRMING THE FOREGOING.

All withdrawals must comply with WV Code § 16-9B-3(b)(2). Verication of compliance must be attached.

Part 4: Additional Certication of tobacco product manufacturer wanting to sell

cigarettes in this State for the rst time.

4.1. If the tobacco product manufacturer has not previously sold cigarettes in this State, complete the following if the

tobacco product manufacturer is a partnership, limited liability company, corporation, association or other business

entity. Please provide the following information, as applicable:

a. The names and addresses of every partner, member, ofcer, resident agent, director or person performing a

function similar to a director:

n a M e S a n d a d d r e S S e S o f P a r t n e r S , M e M B e r S , o f f i c e r S , e t c .

b. The names and addresses of any person owning of record a 10 percent (10%) or greater equity interest in the

tobacco product manufacturer:

n a M e S a n d a d d r e S S e S o f 1 0 % o r g r e a t e r e q u i t y i n t e r e S t S

0.00

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c. List all names under which the tobacco manufacturer, or any partner, member, ofcer, resident agent, director,

or person owning a ten percent (10%) or greater equity interest in the tobacco manufacturer, previously did

business as a tobacco product manufacturer in the United States within the ve-year period preceding the

date of submission of the certication:

4.2. Has the tobacco product manufacturer, or any partner, member, ofcer, resident agent, director, or person owning

a ten percent (10%) or greater equity interest in the tobacco manufacturer, or in any subsidiary, afliate or persons

controlled by or under common control with the tobacco manufacturer, ever been an ofcer, partner, director or person

owning a ten percent (10%) or greater equity interest in a tobacco product manufacturer that ever defaulted in fully

funding the escrow account required by WV Code § 16-9B-1 et seq. in the ve-year period prior to the date of this

certication?

Yes No

If yes, provide a brief explanation of the fact involved (attach additional pages as necessary).

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Part 5: Execution by Authorized Designee

Under penalty of perjury, I certify that the tobacco product manufacturer on whose behalf this certication is

made is in full compliance with WV Code §§ 16-9B-1, including all quarterly installment payments as may be required

by the West Virginia Attorney General; that the information contained in this certication is true and accurate; and

that I am authorized to sign this certication.

Designee (Print Name):

Title:

Mailing Address:

Telephone:

E-mail:

Signature of Designee:

Date:

Subscribed and sworn to

before me on this date:

City or County of:

My Commission expires:

Signature of Notary Public:

MAIL COMPLETED CERTIFICATION TO:

Tobacco Litigation Unit

The Ofce of the Attorney General

State Capitol Complex

Building 1, Room W-435

Charleston, WV 25305

And to:

West Virginia State Tax Department

ATTN: Excise Tax Unit

P.O. Box 2991

Charleston, WV 25330-2991

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SuPPleMental inforMation requireMentS

The West Virginia Attorney General’s ofce also requests the following information:

1. Corporate documents evidencing ofcers and ownership of the NPM;

2. Afdavit from the president of the NPM attesting that it physically manufactures its

cigarettes at its manufacturing facility;

3. The complete address of any facility where the NPM manufactures its cigarettes;

4. Complete list of the brand names of all cigarettes the NPM manufactures or has

manufactured, regardless of where the cigarettes are sold;

5. Copy of the permit as a manufacturer or importer of tobacco products required pursuant to

26 U.S.C. §§ 5712 and 5713; see also 27 C.F.R. Parts 40.62 and 40.375;

6. Copy of the current letter from the HHS/CDC Ofce of Smoking and Health approving the

ingredient reporting;

7. Copy of the current complete rotation plan, including package samples, submitted to the

FTC for approval for each brand;

8. Copy of the FTC rotation plan approval letter for each brand;

9. If the NPM is located in a foreign country:

a. Copy of the license, permit or other registration document required by the government

of the foreign country for a tobacco manufacturer whose manufacturing facilities are

located in such country;

b. Copy of the letter the NPM provides to the importer to comply with 19 U.S.C. § 1681a;

c. Copies of representative brand Custom Forms 7501 for each of the proceeding two

calendar years;

d. If the brand bears a U.S. registered trademark, a certicate signed by the owner of the

trademark stating that, under penalty of perjury, the owner consents to the importation

of cigarettes into the U.S.

e. A certicate signed by the importer stating that, under penalty of perjury, the consent

referred to in the previous paragraph is accurate, remains in effect and has not been

withdrawn.

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