STATE OF ARKANSAS
● -
CONSENT TO SUIT
CERTIFICATION YEAR
2020
*
Due On or Before April 30, 2020
BUSINESS INFORMATION:
Business Name: Contact Person:
Address: City:
State: Zip Code:
Telephone: Email:
CONSENT TO SUIT:
The above-named Non-Participating Manufacturer, does hereby Consent that any action or proceeding against it
pursuant to Act 1099 of 1999, ARK. CODE ANN. §§ 26-57-260 and 26-57-261, and Act 1073 of 2003, ARK.
CODE ANN. §§ 26-57-1301, et seq., as amended, by the State of Arkansas, may be commenced in any state
court of competent jurisdiction within Arkansas.
Initial:
REQUIRED DOCUMENTATION:
Proof of Authority to consent to suit on behalf of the Non-Participating Manufacturer, e.g., a resolution
by the Non-Participating Manufacturer specifically agreeing to the consent to suit provision, as well as
any required approval by an applicable governmental agency, whether federal, state, county, local, or
tribal.
Proof of authority given to the signing party to execute the consent to suit provision.
SIGNATURE:
Authorized Designee: Title:
Designee Signature: Date:
NOTARY:
Subscribed and Sworn Before Me on this Date:
Signature of Notary Public:
City or County of:
My Commission Expires:
MAIL THE COMPLETED CERTIFICATION FORM TO:
Office of the Arkansas Attorney General
ATTN: Tobacco Division
323 Center Street, Suite 200
Little Rock, Arkansas 72201
→ This form, including attachments, must be received on or before April 30,
2020.
→This form will not be
processed unless all fields are completed and all
required attachments have been received.
