Fillable Tobacco Manufacturer Certification Form (Arkansas Attorney General)

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Tobacco Manufacturer Certification Form (Arkansas Attorney General)

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STATE OF ARKANSAS
● -
TOBACCO PRODUCTS MANUFACTURER
CERTIFICATION FORM
CERTIFICATION YEAR
2020
*Due On or Before April 30, 2020
TYPE OF CERTIFICATION:
Initial Certification
Annual Certification
Supplemental Certification
PART 1: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION
Business Name:
Contact Person:
Address:
City:
State/Country:
Zip Code:
Telephone:
Email:
Facsimile:
Webpage:
IS THE COMPANY REPRESENTED BY COUNSEL?
Yes
No
Firm Name:
Counsel’s Name:
Address:
City:
State:
Zip Code:
Telephone:
Email:
Facsimile:
Webpage:
PART 2: DESIGNATION OF TOBACCO PRODUCT MANUFACTURER
AS OF THE DATE OF CERTIFICATION, THE COMPANY IS A:
Participating Manufacturer under the tobacco Master Settlement Agreement that is performing its financial
obligations, as required by ARK. CODE ANN. § 26-57-261.
Non-Participating Tobacco Product Manufacturer in full compliance with ARK. CODE ANN. § 26-57-261,
including all quarterly payments that may be required by ARK. CODE ANN. § 26-57-1305(e).
PART 3: BRAND FAMILY IDENTIFICATION
→ PMs must complete column 1. NPMs must complete columns 1 and 2.
1. Brand Family:
2. Units Sold During Sales Period
Total Number of Units Sold:
→By including a brand family in this Certification Form, a Participating Manufacturer affirms that the brand family is deemed to be
its cigarettes for purposes of calculating its payments under the Master Settlement Agreement. By including a brand family in this
Certification Form, a Non-Participating Manufacturer affirms that the brand family is deemed to be its cigarettes for purposes of
escrow. Despite this, the Office of the Arkansas Attorney General retains the discretion to determine that the listed brand family is the
product of another tobacco product manufacturer.
PACKAGING OR LABELING:
For each Brand Family identified in Part 3 of this Certification Form, provide a copy of the packaging or
labeling.
Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged
FIRE-SAFE COMPLIANCE:
Are each of the cigarette brand families listed herein fire-safe compliant and
certified with Arkansas Tobacco Control, as required pursuant to ARK. CODE
ANN. § 20-27-201, et seq.?
Yes
No
→Copies of the most recent fire-safe certification approval for each brand must be included with this Certification.
If your answer to the preceding question, was “no,” please explain the basis for the request to list the brand on
the Approved-for-Sale Tobacco Products Directory published pursuant to ARK. CODE ANN. § 26-57-1303(b).
Explanation:
DEPARTMENT OF HEALTH AND HUMAN SERVICES INGREDIENT LIST:
For each Brand Family identified in Part 3 of this Certification Form, provide a copy of the Certificate of
Compliance issued by the Department of Health and Human Services, Centers for Disease Control and
Prevention, and the Office on Smoking Health with respect to the ingredient list submission pursuant to 15
U.S.C. § 1335a.
FEDERAL TRADE COMMISSION ROTATION PLAN:
For each Brand Family identified in Part 3 of this Certification Form, provide a copy of the complete warning
rotation plan submitted to the Federal Trade Commission (“FTC”) pursuant to 15 U.S.C. § 1333 and a copy of
the approval letter from the FTC for each brand family.
TOTAL NATIONWIDE SALES ON WHICH FEDERAL EXCISE TAX WAS PAID:
→ In the case of a domestic tobacco product manufacturer, copies of Tobacco Tax Bureau Form 5210.5 supporting the total sales
number must be included with this Certification Form. In the case of a foreign tobacco product manufacturer, a copy of Tobacco Tax
Bureau Form 5220.6 supporting the total sales number must be included.
TOTAL NATIONWIDE SHIPMENTS REPORTED PURSUANT TO 15 U.S.C. § 376:
→ Copies of all reports made pursuant to 15 U.S.C. § 376 must be included with this Certification Form. The company submitting
this form must submit reports to states other than Arkansas pursuant to ARK. CODE ANN. § 26-57-1406.
PART 4: BUSINESS AND OWNERSHIP INFORMATION
A. Participating and Non-Participating Tobacco Product Manufacturers
FABRICATION OF BRAND FAMILIES:
Does the company submitting this certification itself fabricate the brand families
identified in Part 3 of this Certification Form?
Yes
No
If your answer to the preceding question was “no,” please explain the basis for the company’s submission of
this Certification Form.
Explanation:
MANUFACTURING FACILITY IDENTIFICATION:
Facility:
Address:
Manager:
Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged
MANUFACTURER EQUIPMENT IDENTIFICATION:
Type/Name of Equipment:
Manufacturer of Equipment:
Serial Number:
Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged
ACCESS TO MANUFACTURING FACILITY AND EQUIPMENT:
Do other companies have access to or utilize any of the manufacturing facilities
identified herein?
Yes
No
If your answer to the preceding question was “yes,” please explain.
Explanation:
PHOTOGRAPH OR DIAGRAM OF INTERIOR OF MANUFACTURING FACILITIES:
Provide a photograph or diagram of the interior of each of the manufacturing facilities identified herein,
specifically indicating on the photograph or diagram where the manufacturing equipment used in the fabrication
of cigarettes is located.
Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged
PHOTOGRAPH OF EXTERIOR OF MANUFACTURING FACILITIES:
Provide a photograph of the exterior of each of the manufacturing facilities identified herein.
Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged
PROOF OF OWNERSHIP OF MANUFACTURING FACILITIES:
Provide proof of ownership, possession, and control of each of the manufacturing facilities identified herein.
Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged
PROOF OF OWNERSHIP OF MANUFACTURING EQUIPMENT:
Provide proof of ownership, possession, and control of the manufacturing equipment used by the company in
the fabrication of cigarettes at each of the manufacturing facilities identified herein.
Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged
U.S. DEPARTMENT OF TREASURY, TOBACCO TAX BUREAU PERMIT NUMBER:
→ A copy of the permit issued by the U.S. Department of Treasury, Tobacco Tax Bureau must be included with this certification form.
IDENTIFICATION OF WHOLESALERS, DISTRIBUTORS, OR STAMPING AGENTS TO WHOM
CIGARETTES WERE SOLD FOR DISTRIBUTION IN THE STATE OF ARKANSAS:
Wholesaler:
Address:
Telephone:
CRIMINAL ACTIVITY:
Has the company submitting this form or any of its affiliates, sales entity
affiliates, officers, or directors been indicted, pled guilty or nolo contendere to or
been found guilty of a felony crime relating to the sale, taxation, or distribution of
cigarettes or other tobacco products?
Yes
No
If your answer to the preceding question was “yes,” please explain.
Explanation:
DIRECTORY STATUS
Have the company submitting this form, an affiliate of this company, or any of its
brand families been removed or excluded from the approved-for-sale directory of
any state since its last Certification?
Yes
No
If your answer to the preceding question was “yes,” please explain.
Explanation:
ADVERTISING PRACTICES:
Does the company advertise or sell cigarettes via the Internet or in catalogs or
other print media for purposes of selling such cigarettes to individual
consumers, including consumers in the State of Arkansas?
Yes
No
If your answer to the preceding questions was “yes,” please explain.
Explanation:
JENKINS ACT COMPLIANCE:
For each of the past 12 calendar months, has the company provided the reports
required by the Jenkins Act, 15 U.S.C. § 375, et seq., as amended, to the
Arkansas Department of Finance and Administration and Office of the
Arkansas Attorney General?
Yes
No
If your answer to the preceding question was “no,” please explain.
Explanation:
OTHER ADVERSE ACTIONS:
Have there been any adverse actions taken by any Federal or State agency against
the company submitting this form, any of its affiliates, or its brands in the last
three years.
Yes
No
If your answer to the preceding question was “yes,” please explain.
Explanation:
B. Non-Participating Manufacturers Only
IDENTIFICATION OF DIRECTORS, MEMBERS, OFFICERS, AND OWNERS OF THE COMPANY:
Interested Party:
Address:
Telephone:
ASSOCIATION WITH OTHER TOBACCO PRODUCT MANUFACTURERS:
Are any of the individuals or entities identified in the preceding question also
directors, members, officers, owners of other PMs or NPMs?
Yes
No
If your answer to the preceding question was “yes,” please explain.
Explanation:
RECLASSIFICATION OF PRODUCTS AS CIGARETTES OR ROLL-YOUR-OWN:
Have any tobacco products manufactured or sold by the company been
reclassified within the last two years as cigarettes or RYO product by a federal,
state, or local government entity?
Yes
No
If your answer to the preceding question was “yes,” please explain.
Explanation:
PART 5: NON-PARTICIPATING MANUFACTURER CERTIFICATION
NON-PARTICIPATING MANUFACTURER’S REGISTERED AGENT FOR SERVICE OF PROCESS:
Company:
Address:
City:
State:
Zip Code:
Telephone:
Fax:
Email:
→ A statement from the Registered Agent noting his or her service in this capacity must be included with this Certification Form.
Pursuant to Arkansas law, this Registered Agent must reside in the State of Arkansas.
CONSENT TO BE SUED:
Provide an executed copy of the Consent to be Sued form prepared by the Office of the Arkansas Attorney
General.
→ A properly executed copy of the Consent to be Sued form must be included with this Certification Form.
ACCEPTANCE OF JOINT-AND-SEVERAL LIABILITY BY IMPORTERS:
In the case of Non-Participating Manufacturers located outside of the United States, provide an executed copy
of the Acceptance of Joint-and-Several Liability by Importers form prepared by the Office of the Arkansas
Attorney General.
→ A properly executed copy of the Acceptance of Joint-and-Several Liability by Importers form must be included with this
Certification Form.
IMPORTER’S REGISTERED AGENT FOR SERVICE OF PROCESS:
Company:
Address:
City:
State:
Zip Code:
Telephone:
Fax:
Email:
→ A statement from the Registered Agent noting his or her service in this capacity must be included with this Certification Form.
Pursuant to Arkansas law, this Registered Agent must reside in the State of Arkansas.
BONDING:
Does the company submitting this form have a bond in place to cover escrow
liability for sales made in Arkansas during the sales year?
Yes
No
→ If your answer to the preceding question was “yes,” a copy of such bond must be included with this Certification Form.
QUALIFIED ESCROW ACCOUNT:
Financial Institution:
Representative’s Name:
Address:
City:
State:
Zip Code:
Email:
Escrow Account Number:
Arkansas Sub-Account Number:
Date of Escrow Agreement:
→ A copy of the current governing Escrow Agreement and any Amendments thereto must be included with this Certification Form.
ESCROW OBLIGATION FOR SALES PERIOD:
Total Number of Units Sold in Arkansas during Sales Period:
Statutory rate per cigarette ($0.0188482), as adjusted for inflation:
$0.0357965
Multiply Units Sold by the adjusted statutory rate per cigarette:
Amount Deposited for Sales Year:
→ An account statement or letter from the escrow agent must be included with this Certification Form. This account statement or
letter must indicate: (1) the amount deposited, as indicated above and (2) the date of deposit.
→ The inflation adjustment used herein may not be accurate for Quarterly Certifications; the total amount to be deposited into the
Qualified Escrow may need to be recalculated at the time of the Annual Certification.
TOTAL AMOUNT HELD IN ESCROW FOR ARKANSAS:
Total amount held in the Qualified Escrow account for all years:
$
DEPOSITS AND WITHDRAWALS DURING SALES PERIOD:
Date:
Deposit Amount:
Withdrawal Amount:
Balance:
Totals:
$
$
$
→ An account statement from the escrow agent must be included with this Certification Form, indicating the complete account history
for the account/sub-account for the State of Arkansas for all sale years, including all deposits, withdrawals, and a current account
balance.
PART 6: SIGNATURE
Under penalty of perjury, I state that the information contained in this Certification Form is true and correct.
Authorized Designee:
Title:
Designee Signature:
Date:
→ The knowing submission of false or inaccurate information to the Office of the Arkansas Attorney General could result in a civil
penalty being issued against you in an amount up to $10,000.00.
PART 7: NOTARY
Subscribed and Sworn Before Me on this Date:
Signature of Notary Public:
City or County of:
My Commission Expires:
→ Seal of Notary must be included and should overlap the right-hand column of the above box.
PART 8: CHECKLIST AND MAILING
PRIOR TO MAILING, PLEASE ASSURE THAT THE FOLLOWING HAS BEEN PROVIDED:
Brand Family Packaging or Labeling
Exterior Photograph of Facility
Ingredient List
Proof of Ownership of Facility
Rotation Plan
Proof of Ownership of Equipment
Tobacco Tax Bureau Form 5000.24 or 5220.6
U.S. Department of Treasury Permit
Nationwide Reports Under 15 U.S.C. § 376
Signature
Interior Photography or Diagram of Facility
Notary
IN THE CASE OF A NON-PARTICIPATING MANUFACTURER, PLEASE ALSO ASSURE THAT THE
FOLLOWING HAS BEEN PROVIDED:
Manufacturer’s Statement from Registered Agent
NPM or Importer Bond Documentation
Consent to be Sued
Escrow Agreement and Amendments
Acceptance of Joint-and-Several Liability
Account Statement with Complete History
Importer’s Statement from Registered Agent
MAIL THE COMPLETED CERTIFICATION FORM TO:
Office of the Arkansas Attorney General
ATTN: Tobacco Division
323 Center Street, Suite 200
Little Rock, Arkansas 72201
→Certification Forms, including attachments, must be received on or before
April 30, 2020.
→Certification Forms will be returned and left unprocessed unless all fields are
completed and all required attachments have been received.
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Tobacco Manufacturer Certification Form (Arkansas Attorney General)

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Completed 20 July 2020

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