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Tobacco Products Manufacturer Certification Form - Arkansas

Tobacco Products Manufacturer Certification Form Form. This is a Arkansas form and can be used in Tobacco Attorney General Statewide .
 Fillable pdf Last Modified 1/28/2014
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STATE OF ARKANSAS TOBACCO PRODUCTS MANUFACTURER CERTIFICATION FORM CERTIFICATION YEAR 2013 *Due On or Before April 30, 2013 TYPE OF CERTIFICATION: Initial Certification Annual Certification Supplemental Certification PART 1: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION BUSINESS INFORMATION: Business Name: Address: State/Country: Telephone: IS THE COMPANY REPRESENTED BY COUNSEL? IDENTIFICATION OF COUNSEL: Firm Name: Address: State: Telephone: Contact Person: City: Zip Code: Email: Yes No Counsel's Name: City: Zip Code: Email: 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 generally 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: American LegalNet, Inc. www.FormsWorkFlow.com 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 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 5000.24 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 SALES 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. American LegalNet, Inc. www.FormsWorkFlow.com 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? If your answer to the preceding question was "yes," please explain. Explanation: Yes No American LegalNet, Inc. www.FormsWorkFlow.com 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 ARKAN
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