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Non-Participating Tobacco Product Manufacturer Certificate Of Compliance - Ohio
| Non-Participating Tobacco Product Manufacturer Certificate Of Compliance Form. This is a Ohio form and can be used in Tobacco Enforcement Section Attorney General Office Statewide . |
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Executive Agencies Tobacco Enforcement Unit Office: 614-387-5600 Fax: 614-387-5597 30 E. Broad Street, 26th Floor Columbus, Ohio 43215 www.OhioAttorneyGeneral.gov STATE OF OHIO NON-PARTICIPATING TOBACCO PRODUCT MANUFACTURER CERTIFICATE OF COMPLIANCE Pursuant to R.C. 1346.02 and 1346.05 And Ohio Adm.Code 109:8-1-01 thru 109:8-1-03 PART 1: NON-PARTICIPATING TOBACCO PRODUCT MANUFACTURER IDENTIFICATION A. Complete company information below (please type or print): Company Name Federal Mfg. Permit No.: TP Address City/State/Zip/Country Telephone Number: Name/Title of Person Completing Form Fax Number E-Mail Address Website URL P.O. Box B. This form is (check one below): __ Initial Certification Manufacturer is not currently listed on the Ohio Tobacco Directory. __ Annual Certification - Due April 30, 2012 for Ohio sales in 2011 __ Supplemental Certification Change of information provided to the Attorney General. PART 2: NON-PARTICIPATING MANUFACTURER BRAND FAMILY IDENTIFICATION (ATTACH ADDENDUM IF NECESSARY) The Tobacco Product Manufacturer seeks to certify the following brand families and accepts escrow responsibility for all cigarettes and RYO sold in Ohio under these brand names. A. List the brands which are being sold by the manufacturer identified in Part 1A and are currently listed on the Ohio Tobacco Directory. Brand Name Cigarette/RYO Brand Name Cigarette/RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO List any new brands that are not currently listed on the Ohio Tobacco Directory which the manufacturer, identified in Part 1A, intends to sell in Ohio. Brand Name Cigarette/RYO Brand Name Cigarette/RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Identify any brands currently listed on the Ohio Tobacco Directory that are no longer being sold by the manufacturer identified in Part 1A. Brand Name Cigarette/RYO Brand Name Cigarette/RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO B. C. Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Form NPM001 (Rev. 10/2012) PART 3: REQUIRED ATTACHMENTS A. For each brand certified in Parts 2A and 2B of this Certificate of Compliance, complete a Brand Identification and Sales Information Form NPM002 (Rev. 03/2012) See: http://www.ohioattorneygeneral.gov/Services/Business/Tobacco-Directory-Search B. Provide a copy of the current U.S. Treasury Tobacco Tax Bureau (TTB) permit as a manufacturer and/or importer as required by 26 U.S.C. §5712 and §5713 must be provided for the tobacco product manufacturer identified in Part 1A of this form. C. To ensure compliance with Ohio Adm.Code 109:8-1-02(A)(5), provide a Statement of Condition from the Ohio Department of Taxation. Please contact the Ohio Department of Taxation at: Ohio Department of Taxation Attn: Gabriel Jacoby 4785 Northland Ridge Blvd. Columbus, Ohio 43229 Phone: 614-387-1808 D. If not previously submitted, or if changed since last submission, provide original packaging for one brand style which is representative of each brand family certified in Parts 2A and 2B of this form. Flat empty cartons and packs are preferred. Submit new packaging each time you change your packaging or add new brand families. Check one below: __ Packaging for each brand family has not been previously submitted/has changed. Samples are enclosed. __ Packaging for each brand family has been previously submitted and has not changed PART 4: ADDITIONAL INFORMATION A. Pursuant to R.C. 3739.07, a manufacturer must submit to the State of Ohio Fire Marshal a certification that its brands meet the requirements of the Reduced Ignition Propensity Standards for Cigarettes. Please check below: __ Each brand family listed in Part 2A and 2B meets the requirements of the Reduced Ignition Propensity Standards for Cigarettes in Ohio. (If not previously submitted, a certification must be submitted with this Certificate of Compliance). B. Pursuant to the federal Prevent All Cigarette Trafficking ("PACT") Act, 15 U.S.C. §§375, et.seq., all persons who sell, transfer, or ship cigarettes (including roll-your-own tobacco) in interstate commerce for profit, or who offers cigarettes for such a sale, transfer, or shipment must: (1) register with the tobacco tax administrator of the state into which shipment is made; and (2) file monthly reports with the tobacco tax administrator (Ohio Department of Taxation), no later than the 10th of each month, identifying the brands, quantities, and recipients of cigarette shipments into such state. Please check below: __ The Tobacco Product Manufacturer listed in Part 1A is in full compliance with the PACT Act, including but not limited to: registering and filing monthly reports with the Ohio Department of Taxation. C. Pursuant to R.C. 2927.023 the shipment of cigarettes to anyone in Ohio other than "authorized recipients" of tobacco products, as that term is defined in R.C. 2927.023(A)(1), is strictly prohibited. Ohio law requires that all direct cigarette sales to Ohio consumers be made in a "faceto-face" transaction. Thus, cigarettes cannot be sold via the Internet to Ohio consumers. Please check below: __ The Tobacco Product Manufacturer listed in Part 1A is in full compliance of R.C. 2927.023. Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Form NPM001 (Rev. 10/2012) PART 5: NON-PARTICIPATING MANUFACTURER REGISTERED AGENT Check one below: __ The non-participating manufacturer identified in Part 1A is registered to do business in Ohio. __ The non-participating manufacturer identified in Part 1A has appointed and continues to engage the following agent located in Ohio. A current letter (dated this year) from the registered agent accepting this appointment must be attached. Name of Registered Agent Address Telephone Number: City Fax Number State Zip PART 6: NON-PARTICIPATING MANUFACTURER QUALIFIED ESCROW ACCOUNT A. Escrow Account Information The non-participating manufacturer identified in Part 1A has established and continues to maintain the following qualified escrow fund under R.C. 1346.02. Name of Financial Institution Address Contact Name/Title Telephone Number: Escrow Account Number Fax Number Ohio Sub-Account Number Provide name of any security interest in escrow account City State Zip Country B. The following are part of the Certification and must be sent to the Ohio Attorney General's Office directly f
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