Fillable State of West Virginia Certification of Tobacco Product (State of West Virginia)

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State of West Virginia Certification of Tobacco Product (State of West Virginia)

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State of West Virginia
Certification of Tobacco Product Manufacturer That
Signed Master Settlement Agreement
(Pursuant to WV Code § 16-9D-3)
Part 1: Tobacco Product Manufacturer Identification
Tobacco Company Manufacturer Information
Company Name:
Street Address:
City:
State/Country:
Postal Code:
Telephone:
Fax:
Email:
Name/Title of Person
Completing Report:
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Part 2: Brand Family Identification (attach additional sheets if
necessary)
The Participating Manufacturer identified in Part 1 has the following Brand Families,
each of which the manufacturer hereby affirms are to be deemed its Cigarettes for
purposes of calculating its payments under the Master Settlement Agreement for the
relevant year, in the volume and shares determined pursuant to the Master Settlement
Agreement.
Brand Families (List Below)
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Part 3: Execution by Authorized Designee
Under penalty of perjury, I state that the information contained in this Certification is true
and accurate.
Designee (Print Name):
Title:
Mailing Address:
Telephone:
Email:
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 the completed certificate of compliance to:
Tobacco Litigation Unit and West Virginia State Tax Department
The Office of the Attorney General Excise Tax Unit
State Capitol Complex P.O. Box 2991
Building 1, Room W-435 Charleston, WV 25330-2991
Charleston, WV 25305
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State of West Virginia Certification of Tobacco Product (State of West Virginia)

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Completed 13 August 2020

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