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Tobacco Product Manufacturer Certificate Of Compliance - Alabama
| Tobacco Product Manufacturer Certificate Of Compliance Form. This is a Alabama form and can be used in Tobacco Tax Alabama Department Of Revenue Statewide . |
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ALABAMA DEPARTMENT OF REVENUE BUSINESS & LICENSE TAX DIVISION TOBACCO TAX SECTION P.O. Box 327555 · Montgomery, AL 36132-7555 · (334) 242-9627 www.revenue.alabama.gov TOB: TPM CERT 2/12 Tobacco Product Manufacturer Certificate of Compliance For Sales Year 2011 PART 1 TOBACCO PRODUCT MANUFACTURER (TPM) IDENTIFICATION Company: __________________________________________________________________ FEIN: Address: _____________________________________________________________________________________________________ City: ____________________________ State: _________________ Zip/Postal Code: ______________ Country: _________________ Telephone Number: (_______)_____________________________ FAX Number: (_______)________________________________ E-mail Address: _______________________________________________________________________________________________ Name and Title of Person Completing Report: _______________________________________________________________________ The Tobacco Product Manufacturer identified above is, as of the date of this Certification: (Initial One) _______ A Participating Manufacturer under the Tobacco Master Settlement Agreement. _______ A Tobacco Product Manufacturer in full compliance with Alabama Code Sections 6-12-3 and 6-12A-5(e). PART 2 BRAND FAMILY IDENTIFICATION Participating Manufacturers complete Columns A & B; Non-Participating Manufacturers (NPM) complete Columns A through E. Attach additional sheets if necessary. A. BRAND FAMILY1 B. BRAND NAME C. UNITS SOLD CERTIFICATION YEAR (2011) D. HAS THIS BRAND BEEN SOLD IN 2012? (YES OR NO) E. OTHER MANUFACTURER THAT MANUFACTURED THE BRAND FAMILY IN THE PRECEDING OR CURRENT CALENDAR YEAR (NAME AND ADDRESS) 1Indicate with an asterisk ( ) those brands that will not be sold in Alabama as of the date of certification. * American LegalNet, Inc. www.FormsWorkFlow.com PART 3 NON-PARTICIPATING MANUFACTURER CERTIFICATION A. Registered Agent/Approved Agent for Service of Process Agent Name: _________________________________________________________________________________________________ Company: ____________________________________________________________________________________________________ Address: _____________________________________________________________________________________________________ City: __________________________________________ State: ___________________________ Zip Code: _____________________ Telephone Number: (_______)_____________________________ FAX Number: (_______)________________________________ NOTE: Telephone number and fax number must be Alabama numbers. E-mail Address: _______________________________________________________________________________________________ Registered with the Secretary of State as a foreign corporation or business entity? Yes No Yes No If Yes, Date Registered: __________________________. Is the registration current as of the date of certification? B. Qualified Escrow Fund Financial Institution Name of Institution: ____________________________________________________________________________________________ Address: _____________________________________________________________________________________________________ City: __________________________________________ State: ___________________________ Zip Code: _____________________ Representative Name: ____________________________________________ Telephone Number: (_______)___________________ Escrow Account Number: _______________________________ State Account Number: __________________________________ C. Escrow Deposit/Withdrawal History for Alabama Attach NPM Certificate of Escrow Deposit DATE DEPOSIT WITHDRAWAL2 BALANCE $ $ $ (Initial certification should include a complete history. Annual certifications thereafter should be for the applicable sales year.) PART 4 EXECUTION BY AUTHORIZED AGENT Under penalty of perjury, I state that the statements contained in this certification are true, correct and complete. This certificate is made to induce the State of Alabama to place the above-named manufacturer and its brand family on the Directory of Compliant Tobacco Products and Manufacturers in Alabama. I further certify that the above-named manufacturer is in full compliance with Title 6, Chapter 12, of the Alabama Code. Name of Authorized Agent (Print): ________________________________________________ Title: ___________________________ Signature of Authorized Agent: ___________________________________________________ Date: ___________________________ Subscribed and sworn to before me on this date: ___________________________________ Signature of Notary Public: _____________________________________________________ Notary for the State of: _____________________________ City or County of: ____________________________________________ My Commission expires: _______________________________________________________ Mail the completed TPM Certificate of Compliance to: Alabama Department of Revenue Attn: Commissioner of Revenue P. O. Box 327555 Montgomery, AL 36132 American LegalNet, Inc. www.FormsWorkFlow.com 2 Withdrawals must comply with Alabama Code §6-12-3. Verification of compliance must be provided. ALABAMA DEPARTMENT OF REVENUE SALES, USE & BUSINESS TAX DIVISION TOBACCO TAX SECTION P.O. Box 327555 · Montgomery, AL 36132-7555 · (334) 242-9627 www.revenue.alabama.gov TOB: TPM-INST 2/10 Instructions for Tobacco Product Manufacturer Certificate of Compliance General Information: Certification Pursuant to Title 6, Chapter 12A, Code of Alabama 1975 Who is required to file this certificate of compliance? Any tobacco product manufacturer that intends to sell cigarettes within the State of Alabama, whether directly or through any distributor, retailer, or similar intermediary. This Certification is in addition to any Certificate of Compliance that may be required pursuant to Title 6, Chapter 12, Code of Alabama 1975. Definitions: (a) "Brand Family" means all styles of cigarettes sold under the same trademark and differentiated from one another by means of additional modifiers or descriptors, including, but not limited to, menthol, lights, kings, and 100s, and includes any brand name (alone or in conjunction with any other word), trademark, logo, symbol, motto, selling message, recognizable pattern of colors, or any other indicia of product identification identical or similar to, or identifiable with, a previously known brand of cigarettes. (b) "Cigarette" has the same meaning as in Section 6-12-2 (4) of the Code of
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