Certification Of Tobacco Master Settlement Agreement Status {CG-30}

New York State Department of Taxation and Finance Certification of Tobacco Master Settlement Agreement Status Tobacco product manufacturer information (type or print) Legal name of manufacturer Mailing address (number and street or PO box) State or province Telephone number (include area code or country code) Country Fax number (include area code or country code) CG-30 (2/11) Mark an X in this box if this is an amended certification. Federal employer identification number (EIN) City or town ZIP code Date business began in New York State (month, day, year) ( ) ( ) File annually no earlier than April 16 and no later than April 30 of each year. If this is an amended certification or you are a manufacturer first introducing products for sale in New York State (NYS), see Form CG-30-I, Instructions for Forms CG-30, CG-30.1, and CG-30.2, for When must certifications be filed? Forms CG-30 and CG-30.1, Information Regarding Brands Sold in New York State, must be given to an agent or distributor before the agent may affix NYS cigarette tax stamps to that manufacturer's cigarettes or before a distributor may sell that manufacturer's roll-your-own (RYO) tobacco in NYS. Certification -- Mark an X in the applicable box to indicate that the entity is either a participating or non-participating manufacturer. I certify that the above-named tobacco product manufacturer is: a participating manufacturer in the Tobacco Master Settlement Agreement as defined in Public Health Law (PHL) section 1399-pp that 1. has generally performed its financial obligations under the Tobacco Master Settlement Agreement; or 2. a non-participating manufacturer as defined in the Tobacco Master Settlement Agreement in full compliance with the provisions of PHL section 1399-pp, including all required escrow deposits. I also certify that I have attached Form CG-30.1 listing all brands of cigarettes or RYO tobacco of the above-named tobacco product manufacturer sold for consumption in NYS from January 1 of the previous calendar year until the date of this certification. I also certify that if I am a manufacturer first introducing my products for sale in NYS, I have attached Form CG-30.1 listing all brands I intend to sell in NYS effective: , . (month) (day) (year) If I marked box 2 above certifying that the above-named tobacco product manufacturer is a non-participating manufacturer, I also certify that I have attached to the copies of this certification, which are sent to the Commissioner of Taxation and Finance and the Attorney General of NYS, a copy of Form CG-30.2, Information Regarding Escrow Deposit, covering the calendar year beginning January 1 of the year prior to the year in which this certification is made. If this is an amended certification, and if the above-named tobacco product manufacturer is a non-participating manufacturer, I certify by marking box 2 above that I provided a copy of Form CG-30.2 for the calendar year 20 to the Commissioner of Taxation and Finance and the Attorney General of NYS on , (date of current certification on file). (month) (day) (year) A manufacturer who fails to file a certification, files a false certification, or otherwise violates NYS Tax Law section 480-b or 480-c may be subject to a civil penalty of $5,000 (Tax Law section 481(1)(c)). Under penalty of perjury, I declare that the statements contained in this certification, including any accompanying statements or attachments, are true, correct, and complete, and that I am a person authorized to bind the manufacturer making this certification either under the laws of NYS or of the jurisdiction where the manufacturer resides or is organized. This certification is made to induce NYS tax agents to affix NYS tax stamps, pursuant to the Tax Law, onto the cigarettes of the above-named tobacco product manufacturer that are to be sold within NYS, or to induce NYS tobacco distributors to sell the RYO products of the tobacco product manufacturer in NYS. Authorized signature Printed name Title Date State of New York, County of Subscribed and sworn to or affirmed before me this day of My commission expires: 20 Notary Public: NYS* Seal: *If sworn or affirmed outside of NYS, see Form CG-30-I. American LegalNet, Inc. www.FormsWorkFlow.com