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Participating Tobacco Product Manufacturer Certification Or Pact Act Information - Ohio
| Participating Tobacco Product Manufacturer Certification Or Pact Act Information Form. This is a Ohio form and can be used in Tobacco Enforcement Section Attorney General Office Statewide . |
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Executive Agencies Tobacco Enforcement Unit Office: 614-387-5600 Fax: 614-387-5597 30 E. Broad Street, 26th Floor Columbus, Ohio 43215 www.OhioAttorneyGeneral.gov PARTICIPATING TOBACCO PRODUCT MANUFACTURER CERTIFICATION OF PACT ACT INFORMATION Pursuant to R.C. 1346.02 and 1346.05 And Ohio Adm.Code 109:8-1-01 thru 109:8-1-03 Part 1: Sales Year and Type of Certification Sales Year for this Certification: Complete a separate form for each sales year for which you are certifying. (check one) Type of Certification: (check one) Part 2: Participating Manufacturer Identification Company Name: Part 3: PACT Act Registration 1 2 Has manufacturer registered as a tobacco manufacturer with the Ohio Department of Taxation? Provide the name and address of your Ohio registered agent: Provide a listing of states with which manufacturer has registered as a tobacco manufacturer (attach addendum if necessary): _________________ _________________ Part 4: PACT Act Reports 1 Has manufacturer filed monthly reports of all shipments or transfers of cigarettes and tobacco products into Ohio during 2010 and 2011 with the Ohio Department of Taxation? ___ Yes ___ No Provide a list of states for which manufacturer has filed monthly reports of shipments or transfers of cigarettes and tobacco products in 2011 and 2012 (attach addendum if necessary): _________________ _________________ 3 _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ ___ Yes ___ No ___ Initial ___ 2011 ___ Annual ___ Other ___ Supplemental 3 2 Provide the mode of delivery, including the name and address of the person delivering the cigarettes or other tobacco products into Ohio and other states. Part 5: Miscellaneous Information Provide a list of states into which manufacturer shipped or transferred cigarettes and tobacco products in 2011: 1 _________________ _________________ 2 _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ Provide a list of the name and address of the importers, distributors, wholesalers or retailers to which manufacturer made direct shipments or transfers of cigarettes and tobacco products in 2011. Provide a list of states in which manufacturer advertises or offers for sale cigarettes, RYO, or smokeless tobacco, even if no direct shipments or transfers were made into such states (attach addendum if necessary): _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ 3 Form PM003 (Rev. 10/2012) American LegalNet, Inc. www.FormsWorkFlow.com
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