South Dakota > Statewide > Department Of Revenue > Special Taxes Division > Tobacco
South Dakota Tobacco Product Manufacturer Complementary Legislation Certification - South Dakota
| South Dakota Tobacco Product Manufacturer Complementary Legislation Certification Form. This is a South Dakota form and can be used in Tobacco Special Taxes Division Department Of Revenue Statewide . |
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SOUTH DAKOTA TOBACCO PRODUCT MANUFACTURER COMPLEMENTARY LEGISLATION CERTIFICATION Mail this completed Complementary Legislation Certification and attachments to: South Dakota Department of Revenue Mickelson Building 1302 E. Highway 14 Suite 1 Pierre, SD 57501 Please Type or Print Part 1: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION A. Complete company information below: Company Name Address City/State/Zip Telephone Number E-Mail Address Name/Title of Person Completing Form Address of Manufacturing Plant(s) Name of Factory Manager(s) Phone Number of Factory Manager(s) If located in the US: Manufacturer's Federal Taxpayer ID Number: If located in the US: TTB Tobacco Manufacturer Permit Number: Fax Number of Factory Manager(s) Fax Number Website B. The tobacco product manufacturer identified above, as of the date of this Certification, is (check one below): A Participating Manufacturer [Complete parts 1, 2A and 9] A Non-participating Manufacturer [Complete entire form except 2A] This form is (check one below): Initial Certification Manufacturer is not currently listed on the South Dakota Tobacco Brand Listing Annual Certification Due April 30, 2012 Supplemental Certification Change of information provided to the SD Department of Revenue All manufacturers must update this Certification thirty calendar days prior to any addition to or modification of the Brand Families sold in South Dakota. 1 American LegalNet, Inc. www.FormsWorkFlow.com PART 2: BRAND FAMILY IDENTIFICATION (attach additional sheets if necessary) A. Participating Manufacturer: The Participating Manufacturer identified in Part 1 has the following brand families, each of which the manufacturer hereby affirms are to be deemed its cigarettes for the purposes of calculating its payments under the Master Settlement Agreement, in the volume and shares determined pursuant to the Master Settlement Agreement: Indicate with an asterisk (*) those brands that will not be sold in South Dakota as of the date of this certification. (Attach additional sheet if necessary). NOTE: The South Dakota Department of Revenue retains the discretion to determine that the cigarettes in a brand family constitute cigarettes of another tobacco product manufacturer pursuant to SDCL 10-50-75. Brand Family Name Cigarettes or Roll-Your-Own Cigarettes Cigarettes Cigarettes Cigarettes Cigarettes Cigarettes Cigarettes Cigarettes RYO RYO RYO RYO RYO RYO RYO RYO Brand Family Name Cigarettes or Roll-Your-Own Cigarettes Cigarettes Cigarettes Cigarettes Cigarettes Cigarettes Cigarettes Cigarettes RYO RYO RYO RYO RYO RYO RYO RYO I. Are you requesting that all brand families above be listed on South Dakota's directory? Yes ____ No _____ NOTE: If the answer is "No," then identify the brand families that you are not requesting to be listed: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ II. For each of the above brand families (cigarettes only) provide a copy of the current Federal Trade Commission (FTC) approval letter for health-warning rotation plan. Additional information can be obtained at: Federal Trade Commission 600 Pennsylvania Avenue, N.W. Washington, D.C. 20580 General Information Locator: (202) 326-2222 http://www.ftc.gov III. For each of the above brand families (cigarettes only) provide a copy of the current Center for Disease Control (CDC) ingredient listing compliance letter(s) and a statement as to which brand's ingredients were submitted for each approval letter. Additional information can be obtained at: Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333 Telephone: 1-800-311-3435 http://www.cdc.gov/netinfo.htm 2 American LegalNet, Inc. www.FormsWorkFlow.com B. Non-participating Manufacturer: The Non-participating Manufacturer identified in Part 1 has the following brand families, each of which the tobacco product manufacturer affirms are to be deemed its cigarettes for purposes of SDCL ch. 10-50B: List all brand families sold in the preceding calendar year and at any time in the current calendar year. Indicate by an asterisk (*) any brand no longer being sold in South Dakota as of the date of this certification. .09 oz. of RYO constitutes one unit. Attach additional sheets if necessary. NOTE: The South Dakota Department of Revenue retains the discretion to determine that the cigarettes in a brand family constitute cigarettes of another tobacco product manufacturer pursuant to SDCL 10-50-75. Units sold in South Dakota in 2011 and to date in 2012, identified separately Brand Family Name Cigarettes or Roll-Your-Own Previous Manufacturer (Name & Address) Cigarettes Cigarettes Cigarettes Cigarettes Cigarettes I. RYO RYO RYO RYO RYO Are you requesting that all brand families above be listed on South Dakota's directory? Yes ____ No _____ NOTE: If the answer is "No," then identify the brand families that you are not requesting to be listed: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ II. Provide a sample of the current packaging of each brand within each brand family. Check here if previously supplied packaging samples have not changed. NOTE: If the manufacturer has previously supplied such packaging to the SD Department of Revenue and if such packaging has not changed, samples need not be supplied this year. III. IV. If located in the United States, provide a copy of the latest TTB Tobacco Manufacturer Permit. For each of the above brand families (cigarettes only) provide a copy of the current Federal Trade Commission (FTC) approval letter for health-warning rotation plan. Additional information can be obtained at: Federal Trade Commission 600 Pennsylvania Avenue, N.W. Washington, D.C. 20580 General Information Locator: (202) 326-2222 http://www.ftc.gov 3 American LegalNet, Inc. www.FormsWorkFlow.com V. For each of the above brand families (cigarettes only) provide a copy of the current Center for Disease Control (CDC) ingredient listing compliance letter(s) and a statement as to which brand's ingredients were submitted for each approval letter. Additio
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