Delaware > Statewide > Attorney General > Tobacco Litigation
Certification For Listing On Delaware Directory JUS-TPM1 - Delaware
| Certification For Listing On Delaware Directory Form. This is a Delaware form and can be used in Tobacco Litigation Attorney General Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
State of Delaware CERTIFICATION FOR LISTING ON DELAWARE DIRECTORY (TITLE 29, CHAPTER 60D of the DELAWARE CODE) INSTRUCTIONS JUS-TPM1 Page 1 of 14 Department of Justice Initial Annual Supplemental Renewal Sales Year: 20 13 PLEASE TYPE OR PRINT IN PERMANENT BLUE INK PART I: GENERAL BUSINESS AND OWNERSHIP INFORMATION 1. Applicant Tobacco Product Manufacturer Identification Applicant: Street Address: Mailing Address (if different from above): Phone Number: Facsimile (FAX) Number: E-Mail Address: Website Address: Name/Title of Person Completing Certification: Manufacturing Plant(s) Name and Street Address (if different from above): Manufacturing Plant Phone Number: Manufacturing Plant Facsimile (FAX) Number Name/Title/Phone Number of Person at Plant if different from above: (Attach additional sheet(s), as necessary, to provide a complete response) Please attach a photograph or diagram of your manufacturing facility and indicate on the photograph or diagram where the equipment and facilities for manufacturing (i.e., fabricating) the Cigarettes, if any, are located. 2. The undersigned certifies that as of the date of this Certification, the abovenamed applicant is: (initial one) Updated: 01/10/2013 American LegalNet, Inc. www.FormsWorkFlow.com State of Delaware CERTIFICATION FOR LISTING ON DELAWARE DIRECTORY (TITLE 29, CHAPTER 60D of the DELAWARE CODE) INSTRUCTIONS JUS-TPM1 Page 2 of 14 Department of Justice a Participating Manufacturer (PM). (If applicant is a PM, it may skip the remainder of Part I and go directly to Part II.) a Non-Participating Tobacco Product Manufacturer ("NPM") in full compliance with Delaware's statutes including having made all required deposits into a Qualified Escrow Fund for all years beginning with year 1999 sales. 3. Applicant is the manufacturer (i.e., fabricator) of the brands listed in this Certification which are intended to be sold in the United States, including Cigarettes intended to be sold in the United States through an importer. Yes ____ No ____ 4. Applicant is the first purchaser anywhere for resale in the United States of Cigarettes manufactured anywhere that the manufacturer does not intend to be sold in the United States. Yes ____ No ____ If the answer is "Yes," identify each Cigarette manufacturer, (i.e., fabricator), its plant street address, mailing address, contact person, telephone, facsimile phone numbers, and the relationship applicant. Identify the location of the transfer of ownership of Cigarettes and a copy of every agreement or contract between applicant and fabricator. Attach additional sheet(s), as necessary, to provide a complete response. 5. Applicant is a successor of an entity described in questions 3 or 4 above (i.e., manufacturer or first importer). Yes____ No____ 6. If applicant answered "no" to questions 3, 4, and 5 above, explain the basis for applicant's claim that it is a Tobacco Product Manufacturer as defined under Section 6081(i) of Title 29 of the Delaware Code and submit all documentation to support applicant's contention. Attach additional sheet(s), as necessary, to provide a complete response. Updated: 01/10/2013 American LegalNet, Inc. www.FormsWorkFlow.com State of Delaware CERTIFICATION FOR LISTING ON DELAWARE DIRECTORY (TITLE 29, CHAPTER 60D of the DELAWARE CODE) INSTRUCTIONS JUS-TPM1 Page 3 of 14 Department of Justice 7. Licenses/Permits: Division of Revenue for the State of Delaware, License Number as tobacco product seller: Please list any additional licenses obtained from the DOR and their numbers: Attach copies of all current and valid licenses from the DOR. b. U.S. Treasury, Tobacco Tax Bureau (TTB) Permit Number as a manufacturer: Attach a copy of applicant's current permit and/or an importer: as a manufacturer or importer pursuant to 26 USC Chapter 52, and regulations issued thereunder. PART II: BRAND FAMILY IDENTIFICATION 1. Brand Family Identification C. Manufacturer of Brands Listed (Include complete address information) (PMs complete column A; NPMs complete columns A through C) A. BRAND FAMILY (Indicated with an B. Units Sold in Preceding Calendar asterisk (*) those brands that will not be sold Year in 2013) Attach additional sheet(s), as necessary, to provide a complete response. Attach samples of the actual packing and labeling for each brand of Cigarettes that applicant intends to sell in Delaware. 2. Trademark Holder (If applicant is a PM, it may skip Question 2 and go directly to DECLARATION, ACKNOWLEDGEMENT AND SIGNATURE, page 14.) Provide the name, address, phone number of the trademark holder(s) of each brand listed above. Brand Trademark Holder and Contact Physical address Phone Person Attach additional sheet(s), as necessary, to provide a complete response. Updated: 01/10/2013 American LegalNet, Inc. www.FormsWorkFlow.com State of Delaware CERTIFICATION FOR LISTING ON DELAWARE DIRECTORY (TITLE 29, CHAPTER 60D of the DELAWARE CODE) INSTRUCTIONS JUS-TPM1 Page 4 of 14 Department of Justice PART III: ADDITIONAL BUSINESS INFORMATION 1. Organizational Documents to Be Attached (See Instructions for list of documents required by this question) 2. Company Officers & Owners Complete the table by listing all company officers and company owners (all Persons with an equity interest of 10% or more in applicant company.) Attach additional sheet(s), as needed, to provide a complete response. President Partner Vice Pres. Partner Secretary Partner Treasurer Partner 1. CHECK Other Other Other Other APPROPRIATE TITLE 2. Full Name (first, middle, last) 3. Street Address ________________ ________________ ________________ ________________ 4. Telephone # and Facsimile # 5. Date and Place of Birth 6. E-mail Address 3. Affiliates (see Instructions for further information) Attach additional sheet(s), as necessary, to provide a complete response. Brand Family Affiliate Name Type of Business Affiliate: Street Address 4. Applicant Information Please indicate whether the following statements describe applicant by circling either yes or no after the statement. a. b. Applicant sold Cigarettes in Delaware in the preceding calendar year. YES NO Applicant made escrow deposits pursuant to Delaware Statute (29 Del. C. Ch. 60C) in the preceding year. YES NO Updated: 01/10/2013 American LegalNet, Inc. www.FormsWorkFlow.com State of Delaware CERTIFICATION FOR LISTING ON DELAWARE DIRECTORY (TITLE 29, CHAPTER 60D of the DELAWARE CODE) INSTRUCTIONS JUS-TPM1 Page 5 of 14 Department of Justice c. Applicant sold i
|
|||||||
