US Importer Declaration Form

State of Tennessee Office of the Attorney General and Reporter Revenue Section Tobacco Enforcement Division Post Office Box 20207 Nashville, TN 37202-0207 United States Importer Declaration Form Pursuant to Tenn. Code Ann. §§ 67-4-2601 et seq. Certification Year: __________ This Declaration must be executed by an officer of the Importer with authority to bind the Importer to the requirements of Tennessee law as stated below. Execution of this Declaration is an assertion that all information provided is true and correct, and that the Importer accepts and agrees to all the terms specified below. StSTATUTORY REQUIREMENTS Pursuant to Tenn. Code Ann. § 67-4-2602, a Non-Participating Manufacturer ("NPM") located outside of the United States must provide a declaration from each of its importers to the United States that such importer accepts joint and several liability with the NPM for: 1. 2. 3. All escrow deposits due under subsection Tenn. Code Ann. § 47-13-103(a)(2)(A). All penalties assessed under subsection Tenn. Code Ann. § 47-31-103(a)(3). Payment of all costs and attorney fees pursuant to any successful action under Tenn. Code Ann. §§ 47-31-101 et seq., against said manufacturer. Further, the importer has appointed a registered agent for service of process in this state according to the same requirements as established in this part for any non-resident or foreign non-participating manufacturer that has not registered to do business in this state as a foreign corporation or business entity. Submit this completed form and all attachments with the Annual Directory Certification Application. Mail to: Office of the Tennessee Attorney General and Reporter Revenue Section Tobacco Enforcement Division P.O. Box 20207 Nashville, TN 37202 Revised January 2016 Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Importer Declaration Form IMPORTER INFORMATION Importer Name: ________________________________________________________________ Type of Business entity: Sole Proprietorship General Partnership Limited Partnership Corporation Limited Liability Other (specify): __________________________________________________________ Include with Declaration: Attached N/A A copy of the current Articles of Incorporation A copy of the current Certificate of Limited Partnership A copy of the current Articles of Organization A copy of the Importer's current Tobacco Importer's Permit issued by the United States Alcohol and Tobacco Trade Bureau, with any amendments. Trading as (list all names ever used): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Federal Employers Identification Number: ___________________________________________ Federal Tobacco Importer Identification Number: _____________________________________ Physical Address: _______________________________________________________________ ______________________________________________________________________________ Mailing Address: _______________________________________________________________ ______________________________________________________________________________ Contact Name and Title: _________________________________________________________ Phone Number: __________________________ Fax Number: ___________________________ E-mail Address: ________________________________________________________________ Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Importer Declaration Form List the name, title and dates of service for all current and past Officers, Directors and/or Partners: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ NON-PARTICIPATING MANUFACTURER IDENTIFICATION Importer declares that it is a United States importer for the following NPM. Please identify the foreign NPM whose products you import into the United States. The Importer must complete this form for each manufacturer it represents; multiple NPMs may not be included on the same form. Manufacturer Name: ____________________________________________________________ Mailing Address: _______________________________________________________________ ______________________________________________________________________________ Phone Number: ________________________ Fax Number: _____________________________ E-mail Address: _________________________________________________________________ IMPORTER'S RESIDENT AGENT FOR SERVICE OF PROCESS Resident Name: ________________________________________________________________ Mailing Address: _______________________________________________________________ ______________________________________________________________________________ Phone Number: ________________________ Fax Number: _____________________________ E-mail Address: ________________________________________________________________ Proof of Appointment. Attach an original letter from the resident agent accepting appointment as agent for service of process in Tennessee for the relevant sales year. Check the box to acknowledge that the letter is attached to this form. Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Importer Declaration Form If the Tobacco Product Importer is represented by outside counsel for the purpose of compliance with Tenn. Code Ann. §§ 47-31-101 et seq. and 67-4-2601 et seq., provide the following information: Firm Name: ____________________________________________________________________ Attorney: ______________________________________________________________________ Address: _______________________________________________________________________ Phone: __________________________________ Fax: __________________________________ E-mail Address: _________________________________________________________________ The Importer identified above imports into the United States cigarettes manufactured by: ______________________________________________________________________________ List the brand families imported on behalf of the Tobacco Product Manufacturer identified above. ______________________________________________________________________________ __________________________