TOB: TPM CERT 3/11 ALABAMA DEPARTMENT OF REVENUE SALES, USE & BUSINESS TAX DIVISION TOBACCO TAX SECTION P.O. Box 327555 • Montgomery, AL 36132-7555 • (334) 242-9627 www.revenue.alabama.gov Tobacco Product Manufacturer Certificate of Compliance For Sales Year 2010 PART 1 – TOBACCO PRODUCT MANUFACTURER (TPM) IDENTIFICATION Company: __________________________________________________________________ FEIN: អអអអអអអអអ Address: _____________________________________________________________________________________________________ City: ____________________________ State: _________________ Zip/Postal Code: ______________ Country: _________________ Telephone Number: (_______)_____________________________ FAX Number: (_______)________________________________ E-mail Address: _______________________________________________________________________________________________ Name and Title of Person Completing Report: _______________________________________________________________________ The Tobacco Product Manufacturer identified above is, as of the date of this Certification: (Initial One) _______ A Participating Manufacturer under the Tobacco Master Settlement Agreement. _______ A Tobacco Product Manufacturer in full compliance with Alabama Code Sections 6-12-3 and 6-12A-5(e). PART 2 – BRAND FAMILY IDENTIFICATION Participating Manufacturers – complete Columns A & B; Non-Participating Manufacturers (NPM) – complete Columns A through E. Attach additional sheets if necessary. A. BRAND FAMILY1 B. BRAND NAME C. UNITS SOLD CERTIFICATION YEAR (2010) D. HAS THIS BRAND BEEN SOLD IN 2011? (YES OR NO) E. OTHER MANUFACTURER THAT MANUFACTURED THE BRAND FAMILY IN THE PRECEDING OR CURRENT CALENDAR YEAR (NAME AND ADDRESS) 1Indicate with an asterisk ( ) those brands that will not be sold in Alabama as of the date of certification. * American LegalNet, Inc. www.FormsWorkFlow.com PART 3 – NON-PARTICIPATING MANUFACTURER CERTIFICATION A. Registered Agent/Approved Agent for Service of Process Agent Name: _________________________________________________________________________________________________ Company: ____________________________________________________________________________________________________ Address: _____________________________________________________________________________________________________ City: __________________________________________ State: ___________________________ Zip Code: _____________________ Telephone Number: (_______)_____________________________ FAX Number: (_______)________________________________ NOTE: Telephone number and fax number must be Alabama numbers. E-mail Address: _______________________________________________________________________________________________ Registered with the Secretary of State as a foreign corporation or business entity? អ Yes អ No If Yes, Date Registered: __________________________. Is the registration current as of the date of certification? អ Yes អ No B. Qualified Escrow Fund – Financial Institution Name of Institution: ____________________________________________________________________________________________ Address: _____________________________________________________________________________________________________ City: __________________________________________ State: ___________________________ Zip Code: _____________________ Representative Name: ____________________________________________ Telephone Number: (_______)___________________ Escrow Account Number: _______________________________ State Account Number: __________________________________ C. Escrow Deposit/Withdrawal History for Alabama – Attach NPM Certificate of Escrow Deposit DATE WITHDRAWAL2 DEPOSIT $ $ BALANCE $ (Initial certification should include a complete history. Annual certifications thereafter should be for the applicable sales year.) PART 4 – EXECUTION BY AUTHORIZED AGENT Under penalty of perjury, I state that the statements contained in this certification are true, correct and complete. This certificate is made to induce the State of Alabama to place the above-named manufacturer and its brand family on the Directory of Compliant Tobacco Products and Manufacturers in Alabama. I further certify that the above-named manufacturer is in full compliance with Title 6, Chapter 12, of the Alabama Code. Name of Authorized Agent (Print): ________________________________________________ Title: ___________________________ Signature of Authorized Agent: ___________________________________________________ Date: ___________________________ Subscribed and sworn to before me on this date: ___________________________________ Signature of Notary Public: _____________________________________________________ Notary for the State of: _____________________________ City or County of: ____________________________________________ My Commission expires: _______________________________________________________ Mail the completed TPM Certificate of Compliance to: Alabama Department of Revenue Attn: Commissioner of Revenue P. O. Box 327555 Montgomery, AL 36132 2 Withdrawals must comply with Alabama Code §6-12-3. Verification of compliance must be provided. American LegalNet, Inc. www.FormsWorkFlow.com TOB: TPM-INST 2/10 ALABAMA DEPARTMENT OF REVENUE SALES, USE & BUSINESS TAX DIVISION TOBACCO TAX SECTION P.O. Box 327555 • Montgomery, AL 36132-7555 • (334) 242-9627 www.revenue.alabama.gov Instructions for Tobacco Product Manufacturer Certificate of Compliance General Information: Certification Pursuant to Title 6, Chapter 12A, Code of Alabama 1975 Who is required to file this certificate of compliance? Any tobacco product manufacturer that intends to sell cigarettes within the State of Alabama, whether directly or through any distributor, retailer, or similar intermediary. This Certification is in addition to any Certificate of Compliance that may be required pursuant to Title 6, Chapter 12, Code of Alabama 1975. Definitions: (a) “Brand Family” means all styles of cigarettes sold under the same trademark and differentiated from one another by means of additional modifiers or descriptors, including, but not limited to, menthol, lights, kings, and 100s, and includes any brand name (alone or in conjunction with any other word), trademark, logo, symbol, motto, selling message, recognizable pattern of colors, or any other indicia of product identification identical or similar to, or identifiable with, a previously known brand of cigarettes. (b) “Cigarette” has the same meaning as in Section 6-12-2 (4) of the Code of Alabama 1975. (c) “Directory” means the listing of all Tobacco Product Manufacturers that have provided current and accurate certifications conforming to the requirements of Title 6, Chapter 12A, Code of Alabama 1975, and all Brand Families that are listed in such certifications; except as provided by Subsection 6-12A-3 (b). (d) “Distributor” is a person, wherever resident or located, who purchases non-tax-paid cigarettes and stores, sells, or otherwise disposes of the cigarettes. (e) “Master Settlement Agreement” means the Tobacco Master Settlement Agreement as defined under Section 6-12-2 (5). (f) “Non-participating Manufacturer” means any tobacco product manufacturer that is not a participating manufacturer. (g) “Participating Manufacturer” has the meaning given that term in Section II(jj) of the Master Settlement Agreement and all amendments thereto. (h) “Qualified Escrow Fund” has the same meaning as that term is defined in Section 6-12-2 (6). (i) “Tobacco Product Manufacturer” has the same meaning as that term is defined in Section 6-12-2 (9). (j) “Units Sold” has the same meaning as that term is defined in Section 6-12-2 (10). (k) “Wholesaler” means a person, firm, corporation, club, or association that is authorized to affix tax stamps to packages or other containers of cigarettes under the provisions of Title 40, Chapter 25. When is this certificate of compliance due? The TPM Certificate of Compliance must be received no later than April 30th each year for the previous sales year. Specific Instructions: Part 1: Manufacturer’s Identification. Identify the name, FEIN, address, telephone number, fax number and electronic mail address. American LegalNet, Inc. www.FormsWorkFlow.com Part 2: Brand Family Identification. Identify by Brand Family and Brand Name all of the cigarettes that the Tobacco Product Manufacturer intends to sell in this State whether directly or through any distributor, retailer, or similar intermediary, and seeks to have included in the Directory. Only the brands identified may be included in the Directory. A Participating Manufacturer shall include a list of its Brand Families. The Participating Manufacturer shall update such list thirty calendar days prior to any addition to or modification of its Brand Families by executing and delivering a supplemental certification to the Commissioner of the Alabama Department of Revenue. A Non-Participating Manufacturer shall include in its certification (i) a list of all of its Brand Families and the number of Units Sold for each Brand Family that were sold in the State during the certification year, (ii) an answer of yes or no as to whether or not the Brand Families have been sold in the State during the calendar year following the certification year, (iii) indication, by an asterisk, of any Brand Family sold in the State during the preceding calendar year that is no longer being sold in the State as of the date of such certification, and (iv) identification by name and address any other manufacturer of such Brand Families in the preceding or current calendar year. The Non-Participating Manufacturer shall update such list thirty calendar days prior to any addition to or modification of its Brand Families by executing and delivering a supplemental certification to the Commissioner of the Alabama Department of Revenue. Part 3: Non-Participating Manufacturer Certification. A. Verify that the Non-Participating Manufacturer is registered to do business in Alabama or has appointed an agent for service of process and provided notice thereof as required by Section 6-12A-4, Code of Alabama 1975. B. Identify (i) the name, address and telephone number of the financial institution where the Non-Participating Manufacturer has established a Qualified Escrow Fund pursuant to Section 6-12-3, Code of Alabama 1975 and all regulations promulgated thereto; (ii) the account number of such Qualified Escrow Fund and any sub-account number for Alabama. C. Identify (i) the amount such Non-Participating Manufacturer placed in such fund for cigarettes sold in the State during the preceding calendar year, the date and amount of each such deposit; and (ii) the amount and date of any withdrawal or transfer of funds the NonParticipating Manufacturer made at any time from such fund or from any other Qualified Escrow Fund. Part 4: Signature. The person executing the Certification must do so before an authorized notary public who must also sign and date the Certificate. American LegalNet, Inc. www.FormsWorkFlow.com