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Non Participating Manufacturer Certification - Louisiana
| Non Participating Manufacturer Certification Form. This is a Louisiana form and can be used in Tobacco Attorney General Statewide . |
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STATE OF LOUISIANA NON-PARTICIPATING MANUFACTURER CERTIFICATION PURSUANT TO LSA-R.S. 13:5071 et seq. Part 1: Company: Tobacco Product Manufacturer Identification _____________________________________________________________________ Physical Address: _________________________________________________________________ Address: Phone: _____________________________________________________________________ ______________________________ FAX: ________________________________ Alternate Address: ________________________________________________________________ Address: Phone: _____________________________________________________________________ ______________________________ FAX: ________________________________ Name of Person Completing Report: __________________________________________________ Title: Part 2: _______________________________ E-mail: _______________________________ Sales Year By Quarter Year of Sales for this Certificate of Compliance is: __________________ (Complete a separate certification for each year of sales) Part 3: Louisiana Agent for Service of Process (For Companies that have not registered to do business in this State with the Louisiana Secretary of State) Agent Name: _____________________________________________________________________ Company: Address: Address: Phone: E-mail: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ______________________________ FAX: ________________________________ _____________________________________________________________________ Attach proof that this Louisiana Agent has been appointed and continually engaged in this state to act as agent for service of process on whom all process and any action or proceeding against the Tobacco Product Manufacturer concerning or arising out of the enforcement of LSA R.S. 13:5071 et seq. and LSA R.S. 13:5061 et seq., may be served in any manner authorized by law. Date: ________ Initial: ________ 1 American LegalNet, Inc. www.FormsWorkflow.com Part 4: Qualified Escrow Fund Financial Institution Name of Institution: _________________________________________________________________ Address: ______________________________________________________________________ ______________________________ Representative Name: ______________________ Phone: Escrow Acct. No.: ________________________ Date established: _______________________ Date established: _______________________ State Sub-Account No.: _____________________ Attach proof from the Financial Institution of the account balance(s) provided herein, and instruct the Financial Institution to mail monthly statements to this office reflecting the current account balance(s). Has the Escrow Agreement been presented to the Attorney General (date)? ___________________ Date executed?: ________________________________ Amended?: ________________________ (Include all amendments applicable to La.) Escrow Deposit/Withdrawal History for Louisiana Date Deposit Withdrawal Balance Part 5: A. Non-Participating Manufacturer Certifications: That, as of the date of this certification, the certifying Tobacco Product Manufacturer herein, certifies that it is in full compliance with LSA R.S. 13:5061 et seq. and 13:5071 et seq., including all installment payments required by LSA R.S. 13:5075(E); That, the certifying Tobacco Product Manufacturer herein, hereby acknowledges the requirement to hereafter, unless otherwise directed by the Attorney General, make quarterly escrow deposits in order to comply with LSA R.S. 13:5061 et seq.; That, no later than the thirtieth day of April of each of the following years, the certifying Tobacco Product Manufacturer herein, will execute and deliver to the Louisiana Attorney General's Office, a current certification in this same form or another as prescribed by the Louisiana Attorney General's Office. Date: ________ Initial: ________ 2 American LegalNet, Inc. www.FormsWorkflow.com B. C. D. That, as of the date of this certification, the certifying Tobacco Product Manufacturer herein, certifies that the Brand Family/Families listed herein and as attachments, and all supporting information, is true, correct, and complete; That, the certifying Tobacco Product Manufacturer herein hereby affirms that the Brand Family/Families listed herein are deemed to be its cigarettes and/or roll-your-own for purposes of LSA R.S. 13:5061 et seq. and 13:5071 et seq. and that as the certifying manufacturer herein, attests that he/she has read and understands the obligations, responsibilities and laws applicable to all Tobacco Product Manufacturers and NonParticipating Manufacturers pursuant to aforementioned Louisiana laws; That, the certifying Tobacco Product Manufacturer herein, hereby acknowledges that the Brand Family/Families will not be authorized for sale in Louisiana if the "country of origin" on the packaging differs from the "country of origin" listed on the Attorney General's brand directory; That, the certifying Tobacco Product Manufacturer herein, certifies that thirty days prior to the addition to or modification of the Brand Family/Families listed in Attachment #1 and #2, it will execute and deliver a supplemental certification to the Louisiana Attorney General's Office; That, the certifying Tobacco Product Manufacturer herein, certifies that thirty days prior to the termination of the authority of its Louisiana agent, for service of process, it will provide notice to the Attorney General and Secretary of the Department of Revenue, and five days prior to the termination of authority of an agent, for service of process, will provide proof to the satisfaction of the Attorney General of the appointment of a new Louisiana agent, for service of process; That, the certifying Tobacco Product Manufacturer herein, will maintain all invoices and documentation of sales, imports and exports as well as other such information relied upon for such certification for a period of five years, unless otherwise required by law to maintain them for a greater period of time; That, the certifying Tobacco Product Manufacturer herein, hereby acknowledges the requirement to hereafter, unless otherwise directed by the Attorney General, to submit and agree to the jurisdiction of the 19th Judicial District of the Parish of East Baton Rouge over all Non-Participating issues, as detailed in LSA 13:5061 et seq. and 13:50
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