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Participating Tobacco Product Manufacturer Identification - Ohio
| Participating Tobacco Product Manufacturer Identification Form. This is a Ohio form and can be used in Tobacco Enforcement Section Attorney General Office Statewide . |
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STATE OF OHIO PARTICIPATING TOBACCO PRODUCT MANUFACTURER CERTIFICATE OF COMPLIANCE Pursuant to R.C. 1346.02 and 1346.05 And O.A.C. 109:8-1-01 thru 109:8-1-03 Tobacco Enforcement Section 30 E. Broad St., 16th Fl. Columbus, OH 43215-3428 Telephone: (614) 387-5600 Facsimile: (614) 387-5597 www.ohioattorneygeneral.gov PART 1: PARTICIPATING TOBACCO PRODUCT MANUFACTURER IDENTIFICATION A. Complete company information below (please type or print): Company Name Federal Mfg. Permit No.: TP Address City/State/Zip/Country Telephone Number: Name/Title of Person Completing Form Fax Number E-Mail Address Website URL P.O. Box B. This form is (check one below): Initial Certification Manufacturer is not currently listed on the Ohio Tobacco Directory. Annual Certification - Due April 30, 2011 for Ohio sales in 2010 Supplemental Certification Change of information provided to the Attorney General. PART 2: A. PARTICIPATING MANUFACTURER BRAND FAMILY IDENTIFICATION (ATTACH ADDENDUM IF NECESSARY) List the brands which are being sold by the manufacturer identified in Part 1A and are currently listed on the Ohio Tobacco Directory. Indicate with an asterisk (*) those brands not being sold in current year. Attach addendum if necessary Brand Name Cigarette/RYO Brand Name Cigarette/RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO List any new brands that are not currently listed on the Ohio Tobacco Directory which the manufacturer identified in Part 1A intends to sell in Ohio. Brand Name Cigarette/RYO Brand Name Cigarette/RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Identify any brands currently listed on the Ohio Tobacco Directory that are no longer being sold by the manufacturer identified in Part 1A. Brand Name Cigarette/RYO Brand Name Cigarette/RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO B. C. Page 1 of 3 Form PM001 (Rev. 01/2011) American LegalNet, Inc. www.FormsWorkFlow.com PART 3: REQUIRED ATTACHMENTS A. For each brand certified in Parts 2A and 2B of this Certificate of Compliance, complete a Brand Identification and Sales InformationForm PM002 (Rev. 01/2011) See: http://www.ohioattorneygeneral.gov/Services/Business/Tobacco-Directory-Search B. A copy of the current U.S. Treasury Tobacco Tax Bureau (TTB) permit as a manufacturer and/or importer as required by 26 U.S.C. §5712 and §5713 must be provided for the tobacco product manufacturer identified in Part 1A of this form. C. If not previously submitted, or if changed since last submission, provide original packaging for one brand style which is representative of each brand family certified in Parts 2A and 2B of this form. Flat empty cartons and packs are preferred. Submit new packaging each time you change your packaging or add new brand families. Check one below: Packaging for each brand family has not been previously submitted/has changed. Samples are enclosed. Packaging for each brand family has been previously submitted and has not changed PART 4: ADDITIONAL INFORMATION A. Pursuant to R.C. 3739.07, a manufacturer must submit to the State of Ohio Fire Marshal a certification that its brands meet the requirements of the Reduced Ignition Propensity Standards for Cigarettes. Please check below: Each brand family listed in Part 2A and 2B meets the requirements of the Reduced Ignition Propensity Standards for Cigarettes in Ohio. (If not previously submitted, a certification must be submitted with this Certificate of Compliance). B. Pursuant to the federal Prevent All Cigarette Trafficking ("PACT") Act, 15 U.S.C. §§375, et.seq., all persons who sell, transfer, or ship cigarettes (including roll-your-own tobacco) in interstate commerce for profit must: (1) register with the tobacco tax administrator of the state into which shipment is made; and (2) file monthly reports with the tobacco tax administrator (Ohio Department of Taxation), no later than the 10th of each month, identifying the brands, quantities, and recipients of cigarette shipments into such state. Please check below: The Tobacco Product Manufacturer listed in Part 1A is in full compliance with the PACT Act, including but not limited to: registering and filing monthly reports with the Ohio Department of Taxation. C. Pursuant to R.C. 2927.023 the shipment of cigarettes to anyone in Ohio other than "authorized recipients" of tobacco products, as that term is defined in R.C. 2927.023(A)(1), is strictly prohibited. Ohio law requires that all direct cigarette sales to Ohio consumers be made in a "face to-face" transaction. Thus, cigarettes cannot be sold via the Internet to Ohio consumers. Please check below: The Tobacco Product Manufacturer listed in Part 1A is in full compliance of R.C. 2927.023. Form PM001 (Rev. 01/2011) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 PART 5: AFFIDAVIT OF TOBACCO PRODUCT MANUFACTURER This certification MUST be signed by a qualified company officer of the manufacturer identified in Part 1A to bind the applicant company. This form MUST be notarized. My position with the company and my actual authority to certify on behalf of the applicant meets the foregoing requirements: I understand that the Attorney General may require additional information and/or documentation to determine if applicant and/or brands qualify for listing on the Ohio Directory. I have examined this Certification, including attachments and supporting documents and, to the best of my knowledge and belief, this Certification, including attachments and supporting documents, is true, correct, and complete. I understand that in the event the information submitted is no longer accurate, the manufacturer shall notify the Attorney General. On behalf of the Applicant the undersigned agrees that any action or proceeding against it arising from enforcement of the provisions of R.C. 1346.01 through 1346.10 and any rules promulgated pursuant to these statutes, may be commenced against Applicant in any state court within Ohio, that the laws of the State of Ohio will govern such proceedings, and that Applicant waives any immunity from suit, liability, judgment and collection that Applicant may possess. Under penalty of falsification, I state that the tobacco product manufacturer named in Part 1A, as of the date of this certification, is a participating manufac
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