Tobacco Product Manufacturer Certificate Of Compliance | Pdf Fpdf Doc Docx | Montana

Tobacco Product Manufacturer Certificate Of Compliance

Montana/Statewide/Department Of Justice/Tobacco/
Tobacco Product Manufacturer Certificate Of Compliance | Pdf Fpdf Doc Docx | Montana

Tobacco Product Manufacturer Certificate Of Compliance Form

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This is a Montana form that can be used for Tobacco within Statewide, Department Of Justice.

Last updated: 11/30/2016

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MONTANA DEPARTMENT OF JUSTICE Tobacco Product Manufacturer Certificate of Compliance Annual Renewal PLEASE TYPE OR PRINT IN PERMANENT BLUE INK Initial Supplemental Sales Year: 2016 PART I: GENERAL BUSINESS AND OWNERSHIP INFORMATION 1. Applicant Tobacco Product Manufacturer Identification Applicant: Physical Address (street address only - no post office box): Mailing Address (if different from above): Phone Number: E-mail Address: Website Address: Name/Title of Person Completing Certification: Facsimile (FAX) Number: Manufacturing Plant(s) Name and Street Address (if different from above): Manufacturing Plant Phone Number: Manufacturing Plant FAX Number: Name/Title/Phone Number of Person at Plant if different from above: (Attach additional sheet(s), as necessary, to provide a complete response.) 2. The undersigned certifies that as of the date of this Certification, the above-named Applicant is: (initial one) a Participating Manufacturer (PM). a Non-Participating Product Manufacturer (NPM) in full compliance with Montana's Tobacco Product Reserve Fund Statute, Mont. Code Ann.§ 16-11-403, and implementing regulations, including having made all required deposits into a Qualified Escrow Fund for all years beginning with year 1999 sales. 3. Applicant is the manufacturer (i.e., fabricator) of the brands listed in this Certification which are intended to be sold in the United States, including cigarettes intended to be sold in the United States through an importer. Yes No Please attach a photograph or diagram of your manufacturing facility and indicate on the photograph or diagram where the equipment and facilities for manufacturing (i.e., fabricating) the cigarettes, if any, are located. Montana Department of Justice Revised January 2016 Tobacco Product Manufacturer Certificate of Compliance Montana Code Annotated Title 16, Chapter 11, Parts 4 and 5 Page 1 of 12 American LegalNet, Inc. www.FormsWorkFlow.com 4. Applicant is the first purchaser anywhere for resale in the United States of cigarettes manufactured anywhere that the manufacturer does not intend to be sold in the United States. Yes No If the answer is "Yes," identify each cigarette manufacturer (i.e., fabricator), its plant street address, mailing address, contact person, telephone and fax numbers, and the relationship to Applicant. Identify the location of the transfer of ownership of cigarettes and include a copy of every agreement or contract between Applicant and fabricator. Attach additional sheet(s), as necessary, to provide a complete response. 5. Applicant is a successor of an entity described in questions 3 or 4 above (i.e., manufacturer or first importer). Yes No 6. If Applicant answered "No" to questions 3, 4, and 5 above, explain the basis for Applicant's claim that it is a Tobacco Product Manufacturer (TPM) as defined under Mont. Code Ann. § 16-11-402(9) and submit all documentation to support Applicant's contention. Attach additional sheet(s), as necessary, to provide a complete response. 7. Licenses/Permits. a. U.S. Treasury, Tobacco Tax Bureau (TTB) Permit Number as a manufacturer: and/or as an importer: . Attach a copy of Applicant's current permit as a manufacturer or importer pursuant to 26 U.S.C. Chapter 52, and regulations issued thereunder. Montana Department of Justice Revised January 2016 Tobacco Product Manufacturer Certificate of Compliance Montana Code Annotated Title 16, Chapter 11, Parts 4 and 5 Page 2 of 12 American LegalNet, Inc. www.FormsWorkFlow.com PART II: BRAND FAMILY IDENTIFICATION 1. Brand Family Identification (PMs complete column A. PMs affirm that each brand family listed is to be considered its cigarettes for purposes of calculating its payments under the MSA for the relevant year, in the volume and shares determined pursuant to the MSA. NPMs complete columns A through C. NPMs affirm that each brand family listed is to be considered its cigarettes for purposes of Mont. Code Ann. § 16-11-403.) A. Brand Family (Indicate with an asterisk (*) those brands that will not be sold in 2016) B. Units Sold in Preceding Calendar Year C. Manufacturer of Brands Listed (Include complete address information) Attach additional sheet(s), as necessary, to provide a complete response. Attach actual samples or digital copies of the packaging and labeling for each brand of cigarettes that Applicant intends to sell in Montana. If you have already provided samples of a brand, you do not need to provide another sample unless the packaging or labeling has changed from the sample you already provided. (If Applicant is a PM, it may skip Question 2 and go directly to DECLARATION, ACKNOWLEDGMENT AND SIGNATURE, page 12.) 2. Trademark Holder(s) Provide the name, address and phone number of the trademark holder(s) of each brand listed above. Brand Trademark Holder and Contact Person Physical Address Phone Attach additional sheet(s), as necessary, to provide a complete response. Montana Department of Justice Revised January 2016 Tobacco Product Manufacturer Certificate of Compliance Montana Code Annotated Title 16, Chapter 11, Parts 4 and 5 Page 3 of 12 American LegalNet, Inc. www.FormsWorkFlow.com PART III: ADDITIONAL BUSINESS INFORMATION 1. Organizational Documents to be Attached. (See Instructions for list of documents required by this question.) 2. Company Officers & Owners Complete the table by listing all company officers and company owners (all persons with an equity interest of 10 percent or more in Applicant company). Attach additional sheet(s), as necessary, to provide a complete response. 1. CHECK APPROPRIATE TITLE 2. Full Name (First, Middle, Last) 3. Street Address 4. Telephone No./Facsimile No. 5. Date and Place of Birth 6. E-Mail Address President Other Partner Vice Pres. Other Partner Secretary Other Partner Treasurer Other Partner 3. Affiliates (See Instructions for further information) Brand Family Affiliate: Name Type of Business Affiliate: Street Address Attach additional sheet(s), as necessary, to provide a complete response. 4. Applicant Information Please indicate whether the following statements describe Applicant by circling either "Yes" or "No" after the statement: a. b. Applicant sold cigarettes in Montana in the preceding calendar year: Applicant made escrow deposits pursuant to Montana's Tobacco Product Reserve Fund Statute found in Mont. Code Ann. § 16-11-403 in the preceding calendar year: Applicant sold in the preceding calendar year one or more of the Brand Families listed in this