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Non-Participating Manufacturer - Certification Of Additional Information NPM-3 - Illinois
| Non-Participating Manufacturer - Certification Of Additional Information Form. This is a Illinois form and can be used in Tobacco Enforcement Bureau Office Of The Attorney General Statewide . |
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State of Illinois Non-Participating Manufacturer Certification of Additional Information NPM-3 p. 1 of 4 Part 1: Liability Year and Type of Certification Liability Year for this Certification: Complete a separate form for each liability year for which you are certifying. (check one) Type of Certification: (check one) 2012 Other: _____________ Supplemental Initial Annual Part 2: Manufacturer Identification Company Name Mailing Address City Phone State Fax Zip Code Country FEIN Part 3: NPM Status References to cigarettes (includes roll-your-own) are to the brand families certified on the NPM-1 form submitted by the manufacturer identified in Part 2. Yes Yes Yes No No No NPM is the fabricator of the brand families listed on the NPM-1 form and intends for the cigarettes to be sold in the U.S., including cigarettes intended to be sold in the U.S. through an importer. NPM is the first purchaser anywhere for resale in the U.S. of cigarettes manufactured anywhere that the manufacturer does not intend to be sold in the U.S. NPM is a successor as defined in 30 ILCS 168/10. Part 4: Additional Information Requested by Attorney General's Office Check One: Response Provided Does Not Apply All NPMs must provide the information requested in this section. Provide a response to each question or indicate N/A. Each attachment must indicate the question to which it corresponds. 1. A copy of your current U.S. Treasury Tobacco Tax Bureau (TTB) permit as a manufacturer and/or as an importer as required by 26 U.S.C. §5712 and §5713. Foreign NPMs should provide importer permits for each company that will import its cigarettes into the U.S. 2. Name, address and phone number of the Trademark owner and any license agreement or other document providing permission to the NPM to use the trademark for each of the brand families certified in Part 3 of the NPM-1 certification form. 3. A copy of the current corporate documents, such as articles of incorporation, charter or certificate. 4. A listing of all company officers and owners (all persons with an equity interest of 10% or more in company). 5. A complete list of cigarettes (including roll-your-own tobacco) that NPM, its principals, subsidiaries, affiliates, successors, members, officers, owners and directors manufacture no matter where sold; time periods for manufacture of those brands; and place of manufacture for those brands. 6. A complete list of other tobacco products (e.g. cigars, pipe tobacco, smokeless tobacco, etc.) that NPM and its principals, subsidiaries, affiliates, successors, members, officers, owners and directors manufacture no matter where sold; time periods for manufacture of those brands; and the place of manufacture for those brands. American LegalNet, Inc. www.FormsWorkFlow.com State of Illinois Non-Participating Manufacturer Certification of Additional Information NPM-3 p. 2 of 4 Part 4 (continued) : Additional Information Requested by Attorney General's Office Check One: Response Provided Does Not Apply All NPMs must provide the information requested in this section. Provide a response to each question or indicate N/A. Each attachment must indicate the question to which it corresponds. 7. A complete list of Little Cigars that NPM and its principals, subsidiaries, affiliates, successors, members, officers, owners and directors manufacture no matter where sold; time periods for manufacture of those brands; and the place of manufacture for those brands. See definition of "Little Cigars" in Instructions. Please provide packaging for any "Little Cigar" on the Department of Revenue list of cigars classified as cigarettes on or after July 1, 2012 or which continue to be taxed under OTP tax. 8. A list of prior manufacturers of each of the brand families certified in Part 3 of the NPM-1 certification form. 9. For each brand family certified in Part 3 of the NPM-1 certification form, provide the following: a. location of manufacture applies to each brand family yes no (explain) b. name, address and phone number of the factory manager(s) Brand Family c. the date manufacturing d. the price you intend to sell each brand first commenced family to distributors licensed in Illinois American LegalNet, Inc. www.FormsWorkFlow.com State of Illinois Non-Participating Manufacturer Certification of Additional Information NPM-3 p. 3 of 4 Part 4 (continued) : Additional Information Requested by Attorney General's Office Check One: Response Provided Does Not Apply All NPMs must provide the information requested in this section. Provide a response to each question or indicate N/A. Each attachment must indicate the question to which it corresponds. e. identification of intended licensed Illinois distributors f. explanation of manufacturing process and the precise activities that constitute fabrication of the cigarettes or roll-your-own tobacco g. the name, address and contact for the fabricator, if other than the NPM, and a copy of any agreement or contract between the fabricator and NPM regarding the manufacture and/or sale of cigarettes 10. If NPM or any of its principals previously imported or distributed cigarettes or roll-your-own tobacco in the U.S., list each brand family name and the manufacturer name and address for each brand family. 11. If NPM delivers cigarettes directly to a distributor located in and licensed to stamp for Illinois, list all distributors located in and licensed to stamp for Illinois to whom cigarettes were delivered and attach copies of the RC 36 CM reports filed with the Illinois Dept. of Revenue for deliveries during the liability sales year. If NPM does not sell directly to Illinois licensed distributors, provide a list of all importers and/or distributors to which cigarettes or roll-your-own tobacco were sold during the liability sales year. 12. For each brand family of roll-your-own tobacco being certified, state whether NPM pays the Illinois OTP tax and provide a complete list of retailers to whom the roll-your-own tobacco is intended to be sold in Illinois. If NPM pays the Illinois OTP tax, attach a copy of the State of Illinois distributor license. 13. If NPM intends to sell or authorizes any other entity to sell any cigarettes or roll-your-own by mail order or through the internet, provide the internet website and/or identify publications. Attach copies of all reports, if any, filed with the Illinois Dept. of Revenue to comply with the Jenkins Act (Chapter 10A of Title 15 of the U.S. Code, Section 375 et seq.) for sales
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