Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Certification Of Compliance And Affidavit By Nonparticipating Manufacturer Form. This is a Connecticut form and can be use in Department Of Revenue Services Statewide.
Tags: Certification Of Compliance And Affidavit By Nonparticipating Manufacturer, TPM-1, Connecticut Statewide, Department Of Revenue Services
State of Connecticut
Form TPM-1
Certification for calendar year
2010
Certification of Compliance and Affidavit by Nonparticipating Manufacturer
(Rev. 03/11)
Cigarettes Sold to Consumers Within Connecticut During Calendar Year 2010
Complete this form in blue or black ink only. An authorized agent of the nonparticipating manufacturer must complete and sign
Part I before a notary public. The nonparticipating manufacturer is also responsible for having an authorized agent of the financial institution
complete and sign Part II before a notary public and for filing Form TPM-1, Certification of Compliance and Affidavit by Nonparticipating
Manufacturer, with the Office of the Attorney General on or before April 30, 2011. Attach Form TPM-3, Brand Families Unit Sales Schedule,
to this form. Read the additional instructions on the back of this form.
Part I – To be completed by a nonparticipating manufacturer and signed before a notary public.
1. Name of nonparticipating manufacturer
2. Telephone number
(
3. Address
Number and street
PO Box
)
4. Facsimile (Fax) number
(
5c. Country
)
5a. City, town, or post office
5b. State or province
6. Email address
7. Name of financial institution holding the qualified escrow fund for Connecticut
8. Account and sub-account numbers of the qualified escrow fund for Connecticut
9. Number of nonparticipating manufacturer’s cigarettes sold to consumers within Connecticut whether directly or
through a distributor, dealer, or similar intermediary or intermediaries during calendar year 2010
10. Amount required to be placed into the qualified escrow fund for Connecticut sales: Multiply Line 9 by $0.0274350.
$
.
11. Amount placed into the qualified escrow fund for Connecticut and attributable to Connecticut sales reported on Line 9
$
.
$
.
12. Account balance of the qualified escrow fund for Connecticut, including amount reported on Line 11
Declaration: I declare under the penalty of false statement that I have examined Part I of this form and, to the best of my knowledge and
belief, it is true, complete, and correct. The penalty for false statement is imprisonment not to exceed one year, a fine not to exceed $2,000,
or both. I authorize the financial institution named above to verify the balance in the bank account identified above, and any deposits thereto
and withdrawals therefrom, for the State of Connecticut, Office of the Attorney General, upon request by that office.
_______________________________________________________
Signature of authorized agent of nonparticipating manufacturer
_____________________________________________
___________________________
Printed or typed name of authorized agent
Title of authorized agent
Subscribed and sworn to before me this _______________________________________day of ________________________________ , 20
______________________________________________
Signature of notary public
__________
My commission expires: ____________________________
Part II – To be completed by financial institution holding qualified escrow fund and signed before a notary public.
Name of financial institution holding the qualified escrow fund
Address
Telephone number
(
)
Number and street
PO Box
Fax number
(
City, town, or post office
State
ZIP code
)
Email address
Declaration: I declare under penalty of false statement that the nonparticipating manufacturer named above has placed money into the
bank account identified above and that I have examined Part II of this form and, to the best of my knowledge and belief, it is true, complete,
and correct. The penalty for false statement is imprisonment not to exceed one year, a fine not to exceed $2,000, or both. In accordance
with the authorization given by the nonparticipating manufacturer mentioned above, I agree to verify the balance in the account identified
above, and any deposits thereto and withdrawals therefrom, for the State of Connecticut, Office of the Attorney General, upon request
by that office.
_______________________________________________________
Signature of authorized agent of financial institution
_____________________________________________
___________________________
Printed or typed name of authorized agent
Subscribed and sworn to before me this _______________________________________day of ________________________________ , 20
______________________________________________
Signature of notary public
Title of authorized agent
__________
My commission expires: ____________________________
American LegalNet, Inc.
www.FormsWorkFlow.com
Form TPM-1 Instructions
Who Must File
Each nonparticipating manufacturer selling cigarettes to
consumers within Connecticut, whether directly or through a
distributor, dealer, or similar intermediary or intermediaries,
must establish a qualified escrow fund for the benefit of
the State of Connecticut and other settling states, place the
required amount of money into a qualified escrow fund, and
file Form TPM-1, Certification of Compliance and Affidavit
by Nonparticipating Manufacturer.
Definitions
Cigarette means any product that contains nicotine, is
intended to be burned or heated under ordinary conditions
of use, and consists of or contains:
a. Any roll of tobacco wrapped in paper or in any substance
not containing tobacco;
b. Tobacco, in any form, that is functional in the product,
which because of its appearance, the type of tobacco used
in the filler, or its packaging and labeling, is likely to be
offered to or purchased by consumers as a cigarette; or
c. Any roll of tobacco wrapped in any substance containing
tobacco, which because of its appearance, the type of
tobacco used in the filler, or its packaging and labeling,
is likely to be offered to or purchased by consumers as
a cigarette described in (a).
For purposes of this form:
1. Each nine one-hundredths (0.09) of an ounce of
roll-your-own cigarette tobacco also constitutes one
individual cigarette.
2. A small cigar properly treated as a cigarette for
purposes of the federal excise tax on cigarettes
(26 U.S.C. §5701(b)) should be reported as a cigarette
on Form TPM-1, but a small cigar properly treated as
a small cigar for purposes of the federal excise tax on
cigars (26 U.S.C. §5701(a)(1)) should not be reported as
a cigarette on Form TPM-1.
Nonparticipating manufacturer means any tobacco product
manufacturer that is not a participating manufacturer.
Participating manufacturers means and includes the original
participating manufacturers and subsequent participating
manufacturers.
Original participating manufacturers means Brown
& Williamson Tobacco Corporation, Lorillard Tobacco
Company, Philip Morris Incorporated, R.J. Reynolds Tobacco
Company, and their respective successors.
Subsequent participating manufacturer means a tobacco
product manufacturer that becomes a signatory to the
Master Settlement Agreement (MSA) but is not an original
participating manufacturer.
Form TPM-1 Back (Rev. 03/11)
Tobacco product manufacturer means any entity, which after
July 1, 2000, directly and not exclusively through an affiliate:
a. Manufactures cigarettes anywhere which the manufacturer
intends to be sold in the United States, including
cigarettes intended to be sold in the United States through
an importer;
b. 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; or
c. Becomes a successor of an entity described above.
Master Settlement Agreement means the agreement that
the settling states and the original participating manufacturers
entered into on November 23, 1998. Under MSA, the parties
settled and resolved all claims by the settling states directly
or indirectly based on the sale, distribution, manufacture,
development, advertising, and marketing of tobacco products
by the participating manufacturers. MSA required, among
other things, each of the settling states enact a model statute.
Settling states means the 46 states, including Connecticut,
that signed the MSA on or before November 23, 1998.
Qualified escrow fund means an escrow arrangement with
a federally or state-chartered financial institution having
no affiliation with any tobacco product manufacturer. The
financial institution must have assets of at least $1 billion.
The escrow arrangement must require that the financial
institution hold the principal of the escrowed funds for the
benefit of releasing parties (generally, the settling states) and
prohibit the tobacco product manufacturer that placed the
funds into escrow from using, accessing, or directing the use
of the principal of the funds except as consistent with Conn.
Gen. Stat. §4-28i(b).
When and Where to File
On or before April 15, 2011, the nonparticipating
manufacturer must place the required amount of money into
a qualified escrow fund.
On or before April 30, 2011, the nonparticipating
manufacturer must send Form TPM-1, Form TPM-3, Brand
Families Unit Sales Schedule, and a copy of the escrow
agreement signed by the nonparticipating manufacturer
and the financial institution to the following address:
Office of the Attorney General
Finance Department
PO Box 120
Hartford CT 06141-0120
For further information contact:
Office of the Attorney General
State of Connecticut
860-808-5270
American LegalNet, Inc.
www.FormsWorkFlow.com