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Form MDOAG-MSA1 1

STATE OF MARYLAND

OFFICE OF THE ATTORNEY GENERAL

TOBACCO PRODUCT MANUFACTURER CERTIFICATION FORM

(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: ___________________________________________

Form MDOAG-MSA1 2

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

Directory.

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)

Form MDOAG-MSA1 3

Part III: Supplemental Documents- All TPMs (include as separate attachments)

A. Provide a current copy of the TPM’s Maryland Cigarette or OTP Manufacturer

Permit(s).

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

approved.

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.

Form MDOAG-MSA1 4

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: ______________________________________

Instagram:______________________________________

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

Form MDOAG-MSA1 5

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.

Form MDOAG-MSA1 6

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

Maryland

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

satisfaction

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

sting

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

ointment

of a new agent.

Sign and notarize below if you have read and understand the preceding

statements

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

Compleme

ntary Legislation (the Directory Sta

tute).

Name: ________________________________ Date: ________________

Subscribed

to and sworn to before me on this ____ day of _________________,____

Signature of Notary Public: ______________________________

City or County of: _____________________

My Commission Expires: _______________

Form MDOAG-MSA1 7

B. Resident Agent

Name and Address of Resident Agent in the State of Ma

ryland:

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

agent.

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?

□

Yes

□

C. Im

porter

1. Is the NPM located outside the United States? □ Yes □ No

2. If Yes, provide the following information for all importers of the NP

M’s

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 #: ____________________

Form MDOAG-MSA1 8

2. Escrow Agr

eement

Provide to the Attorney General a copy of the current Qualified Escro

Agreement,

including all amendments. The agreement must be dated

after

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

ral.

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

ncluding

the

dates, amounts, and a running

balance.

Has the NPM ever made a withdrawal from the Maryland escrow subaccount?

□

Yes

□ 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

Escrow

Agent is using the default instructions in Section 5 of the Escrow

Agreement.

b. P

rovide an accounting of the full balance in the QEF. Th

accounting

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

informatio

n of the current owner or beneficiary of the QEF.

Form MDOAG-MSA1 9

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

encumbrance

on the interest or principal in the QEF?

□

Yes

□ 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.

NOTE: T

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.

Authorized

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

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