(Pursuant to Md. Code, Bus. Reg. §§ 16-501 to 16-508
Part I: Tobacco Product Manufacturer Identification
Section A.
Type of Certification
Initial Certification □ Annual Certification □ Supplemental Certification
Section B.
Status of Manufacturer
□ Participating Manufacturer
□ Nonparticipating Manufacturer
Section C.
Company Information
Company Name:________________________________________________________
Street Address: _________________________________________________________
City, State, Country, Zip: __________________________________________________
Mailing Address (if different):______________________________________________
City, State, Country, Zip:__________________________________________________
Phone Number: _______________________ Fax: ____________________________
E-mail Address: _______________________ Website: _________________________
Name/Title of Person Completing Certification: ________________________________
Section D. Manufacturing Facility
Factory Address: ________________________________________________________
City, State, Country, ZIP: _________________________________________________
Name of Factory Manager(s): ______________________________________________
Telephone Number of Factory Manager: _________________
E-mail: ___________________________________________
Part II: Brand Family Identification
A. All Tobacco Pro
duct Manufacturers (PMs and NPMs)
For each Brand Family intended to be listed on the Maryland Tobacco Directory
complete a copy of Form MDOAG- MSA1B. Separately identify any NEW brand
families or styles that the manufacturer is seeking to ADD to the Directory, or any
Current brand families or styles that the manufacturer would like to REMOVE from the
B. Nonpartic
ipating Manufacturers ONLY
Indicate the number of Units Sold during the prior calendar year for each brand family
identified in a Form MDOAG- MSA1B. The NPM must include the number of Units
Sold for any and all brands sold during the prior year, even if that brand family is not
being included for listing on the Directory during this certification period. Indicate with
an asterisk (*) those Brand Families that are not intended to be sold in Maryland. If a
particular brand family was acquired from or manufactured by a different TPM within the
past 5 years, provide the name and address of the prior manufacturer(s).
Brand Family
Units Sold in Md.
in the Prior Year
Prior Manufacturer
(name & address)
Part III: Supplemental Documents- All TPMs (include as separate attachments)
A. Provide a current copy of the TPM’s Maryland Cigarette or OTP Manufacturer
B. Provide a c
urrent copy of the TPM’s TTB Importer or Manufacturer Permit(s).
C. Attach a photograp
h or diagram of your manufacturing facility and indicate on the
photograph or diagram where the equipment and facilities for manufacturing (i.e.
fabricating) the cigarettes are located.
D. Provide copies of a
ll approval letters issued by the Office of the Comptroller
within the past 3 years identifying each brand style that has been certified Fire
Safety Standards Compliant within the past three years pursuant to Md. Code
Ann., Bus. Reg. §§ 16-601 et. seq.
E. Provide copies of c
urrent Federal Trade Commission approval letters for the
health warning rotation plan identifying each brand style that has been
F. Provide a c
urrent copy of the ingredient-listing compliance letter from the
Centers for Disease Control and Prevention. If the letter does not identify the
brand families that were approved, provide materials submitted to the CDC
identifying the brands submitted for review.
G. Has the TPM, prev
iously provided a copy of the PACT Act registration with
the State? □ Yes □ No
1. If yes, indicate the date and the corporate name under which the
registration was submitted.
Name: __________________________ Date: _______________
2. If No, provide a copy of the registration form.
H. Is the entit
y owned or operated by a federally recognized Native
American/Indian tribe? □ Yes □ No
If yes, provide a waiver authorized by the official government of the tribe
confirming that the tribe waives any claims to sovereign immunity from a suit
alleging that the TPM has failed to make a required MSA or escrow payment.
Part IV: Social Media Marketing
A. Provide the
URL for any and all websites the TPM uses to market or sell its
brand families.___________________________________________________
B. If the TPM uses an
official account on any of the following social media
accounts/apps, provide the account name:
Facebook: ______________________________________
Twitter: ________________________________________
Snap: __________________________________________
Other: __________________________________________
C. If the TPM use
s other internet or mobile sites/apps/means of marketing its
products direct to consumers, please identify:___________________________
Part V: Good Standing
For each of the following items, if the TPM’s response is “Yes,” attach a
separate page indicating the applicable State and providing the circumstances
surrounding the failure/denial at issue.
A. Has the Tobacco Product Manufacturer ever been denied certification in any
state or removed from a state’s tobacco directory for noncompliance with the
MSA or a state’s escrow requirements? □ Yes □ No
B. If the TPM is a Participating Manufacturer, has the PM ever failed to meet its
financial obligations under the MSA? □ Yes □ No N/A
C. If the TPM is an NPM, has the NPM ever failed to make a timely escrow
deposit in any Settling State? □ Yes □ No N/A
D. If the TPM is an NPM, has the NPM ever been sued by a Settling State for
failure to make a required escrow deposit? □ Yes □ No N/A
E. Has the TPM ever been denied listing or removed from another State’s
Tobacco Directory for a reason other than failure to pay escrow? □ Yes □ No
F. Is the TPM enjoined from selling cigarettes in any state as a result of a court
order, state or federal agency ruling or determination? □ Yes □ No
G. Has the TPM ever failed to timely file or complete a form or document
required by the Maryland Escrow Act or Complementary Legislation? (MD
Code, Bus Reg. Art. §§ 16-401 & 16-501 et seq.) □ Yes □ No
H. Pursuant to MD Code, Bus. Reg. §16-223 and §16.5-217, the direct shipment
of cigarettes or other tobacco products to a consumer, ordered via mail,
telephone, computer or other electronic network, is prohibited by any entity or
person other than a licensed tobacco retailer or tobacconist.
1. Does the certifying TPM engage in the direct shipment of cigarettes or
OTP to consumers in other states, either itself or through an affiliated
distributor? □ Yes □ No
2. The TPM affirms that it will not directly ship cigarettes or OTP to a
Maryland consumer in violation of Bus. Reg. §16-223 and §16.5-217.
Signature o
f Representative: ____________________ Date:_______________
Part VI: Corporate Officers
A. Provide the names of the TPMs Senior Corporate Officers
1. President/CEO: _______________________________________
2. Chief Financial Officer _________________________________
3. General Counsel ______________________________________
4. Chair of the Board of Directors ___________________________
B. If the TPM is a publicly traded corporation, on a separate attachment
provide the names and ownership percentages of all individuals or entities
that own more than 5% of outstanding common stock.
C. If the TPM is private or closely held corporation, on a separate attachment provide the
names, phone numbers, and ownership percentages of all individuals or entities that own
more than 5% of the company.
Part VII: Additional Requirements for Nonparticipating Manufacturers
A. Consent t
o Suit
All nonresident Nonparticipating Manufacturers must consent to be s
ued in
Maryland i
n the event they fail to comply with all Maryland State law
s related
to the manufacture, shipment, and sale of cigarettes or roll-your-own tobacco
into the S
tate. Nonresident, Nonparticipating Manufacturers must als
o register
as a foreign
corporation and record the resident agent information wi
th the
State Department of Assessments and Taxation or maintai
n a
resident agent to accept service of process in Maryland.
All Nonpar
ticipating Manufacturers are required to: 1) provide notic
e to the
Office of the
Attorney General at least thirty (30) calendar days prior
termination of the authority of a resident agent; and 2) provide proof, to the
of the Office of the Attorney General, of the appointmen
t of a new
agent at leas
t five (5) calendar days prior to the termination of the exi
agent appoi
ntment. If an agent terminates the appointme
nt, the
Nonparticipating Manufacturers shall notify the Office of Attorney General
within five
(5) calendar days of the termination with proof of the app
of a new agent.
Sign and notarize below if you have read and understand the preceding
and your company consents to be sued in Maryland if it fail
s to
comply wi
th Maryland State laws related to the manufacture, shipme
nt, and
sale of cigare
ttes or roll-your-own tobacco into the State including, bu
t not
limited to violations the Tobacco Product Manufacturers Escrow Act and
ntary Legislation (the Directory Sta
Name: ________________________________ Date: ________________
to and sworn to before me on this ____ day of _________________,____
Signature of Notary Public: ______________________________
City or County of: _____________________
My Commission Expires: _______________
B. Resident Agent
Name and Address of Resident Agent in the State of Ma
Company: _____
Individual Contact: _______________________________________________
Street Address: __________________________________________________
City, State, Zip: __________________________________________________
Phone Number: __________________ Fax Number: ___________________
E-mail: _________________________________________________________
NOTE: The Nonparticipating Manufacturer must attach to this form a
current let
ter from the resident agent accepting its appointment as
Is the Non
participating Manufacturer registered to do business in
Maryland as a foreign corporation or business entity?
□ Yes □ No If yes, date registered: ________________
Is the registration current as of the date of this certification?
C. Im
1. Is the NPM located outside the United States? □ Yes □ No
2. If Yes, provide the following information for all importers of the NP
products into the United States.
Name: _______________________________________________________________
Address: _____________________________________________________________
City: ________________________ Province, State, Region: ____________________
Country: _____________________ Postal Code: ____________________________
Phone: ______________________ Fax: ___________________________________
E-mail ______________________ Website: _______________________________
Contact: ____________________________________________________________
Brands to be Imported: _________________________________________________
D. Qu
alified Escrow Fund
1. Financial Instituti
Name of Institution: ____________________________________________________
Address: _____________________________________________________________
Representative Name: ___________________________________________________
Telephone Number: __________________ Fax Number: ______________________
Escrow Acct. #: __________________ State Sub-account #: ____________________
2. Escrow Agr
Provide to the Attorney General a copy of the current Qualified Escro
including all amendments. The agreement must be dated
January 1, 2017 and contain and conform to the revised model language
currently ava
ilable on the website of the Office of the Attorney Gene
Date of Escr
ow Agreement: __________________
No changes to a Qualified Escrow Agreement may be made without prior
authorization of the Attorney General.
3. Escrow De
posit History for Maryland
On a separate sheet(s) of paper, attach a ledger for the NPM’s Maryland
escrow sub
-account identifying all escrow deposits and withdrawals, i
dates, amounts, and a running
Has the NPM ever made a withdrawal from the Maryland escrow subaccount?
□ No If yes, attach an explanation on a separate sheet of paper.
4. Investment
a. Provide copies of all written instructions provided by the NPM to
the Escrow
Agent. If investment instructions are oral, prov
ide a
detailed su
mmary of the instructions. If no instructions ha
been given t
o the Escrow Agent, please confirm that the
Agent is using the default instructions in Section 5 of the Escrow
b. P
rovide an accounting of the full balance in the QEF. Th
must identify the amounts and types of all asse
ts in
the account, as well as the date of purchase, the par value, and
cost basis
of those assets.
Ownership of Escrow Accounts
a. Is the Certifying TPM the current owner and beneficiary of the
QEF? □
Yes □ No
b. If No, on a separate page provide the name an
d contact
n of the current owner or beneficiary of the QEF.
c. Has the NPM sold any rights to receive the income or principal
from the Q
EF in the future? □ Yes □ No
d. If Yes, provide the Name and contact information of any
and all
future owne
rs or beneficiaries of the QEF.
e. Does any entity have a lien, security interest, or other
on the interest or principal in the QEF?
□ No
f. If
yes, provide the name and contact information of any a
nd all
such creditors or beneficiaries.
E. Identification of Licensed Wholesaler Stamping Agents
All cigarettes sold in Maryland must be stamped by a licensed tobacco wholesaler.
On a separate page, list the name, address, and phone number of each licensed
wholesaler stamping agent that has sold or through which the Nonparticipating
Manufacturer intends to sell its your cigarette or RYO brands in Maryland.
he Nonparticipating Manufacturer must update this Part VII.E if it
uses distributors not identified above to sell its products in Marylan
It is the responsibility of a Nonparticipating Manufacturer to identify all sales
of its prod
ucts into the State and to ensure that it has deposited suffici
ent funds
satisfy its escrow deposit obligations. Please contact our office if
wholesaler r
efuses to provide the Nonparticipating Manufacturer t
information necessary to meet its legal obligations.
Form MDOAG-MSA1 10
Part VIII. Execution by Authorized Designee
___ I state that
the tobacco product manufacturer named in Part I, as of the date of
this certification, is a Participating Manufacturer in full compliance with all
applicable sections of the Tobacco Product Manufacturers Escrow Act, as
codified in Md. Code Ann., Bus. Reg. §§ 16-401 to 16-403 and has met its
financial obligations under the Tobacco Master Settlement Agreement.
___ I state that the tobacco product manufacturer named in Part I, as of the date of
this certification, is a Nonparticipating Manufacturer in full compliance with
all applicable sections of the Tobacco Product Manufacturers Escrow Act, as
codified in Md. Code Ann., Bus. Reg. §§ 16-401 to 16-403.
Under penal
ty of perjury, I certify and declare that I have examined and reviewed this
certification and that all of the statements and information contained in this
certification, including but not limited to any accompanying statements, documents,
or attachments herewith, are true, correct, accurate, and complete.
I understan
d that the Attorney General may require additional information and/or
documentation to determine whether the Tobacco Product Manufacturer is in
compliance with all applicable State and federal laws.
I am an offic
er or owner of the certifying Tobacco Product Manufacturer authorized
to bind the manufacturer either under the laws of the State of Maryland or the
jurisdiction where the manufacturer resides or is organized.
Officer: ______________________________ Title: _________________
Signature: ______________________________________ Date: _________________
Subscribed to and sworn to before me on this ____ day of ________________,_____
Signature of Notary Public: ______________________________________________
City or County of: _____________________
My Commission Expires: _______________
Mail the com
pleted certification to:
Tobacco Enforcement Unit, Office of the Attorney General of Maryland
Attn: Aravind Muthukrishnan, Assistant Attorney General
200 St. Paul Place, 20th Floor
Baltimore, Maryland 21202