NPM-2 State of Illinois Non-Participating Manufacturer Certification of Appointment of Agent for Service of Process Please Review Instructions Prior to Completion. Part 1: Liability Year and Type of Certification Liability Year for this Certification: Complete a separate form for each liability year for which you are certifying. (check one) ☐ 2010 ☐ Other: Type of Certification: ☐ Annual ☐ Supplemental ☐ (check one) Initial ______ Part 2: Manufacturer Identification Company Name Mailing Address City State Phone Zip Code Country Fax FEIN Part 3: Manufacturer Status (Check one) ☐ The NPM certifies that it is registered to do business in Illinois. (Attach certification from Illinois Secretary of State.) ☐ The NPM certifies that it is a non-resident or foreign NPM that has not registered to do business in Illinois, and hereby certifies that it has appointed an agent, located within the State of Illinois, to receive service of process on its behalf. (Complete Part 4 and attach proof of appointment and availability of Agent.) Part 4: Agent Appointed for Service of Process Company Contact Name Physical Address City State Zip Code City State Zip Code Phone Fax E-Mail Mailing Address Availability of Agent (hours of business) Part 5: Manufacturer Certification Under penalties of perjury, I state that, to the best of my knowledge, all of the information contained in this Certification and any attached documents are true and accurate. This document must be signed and dated by an authorized notary public. NPM Authorized Designee (Print Name) Title Signature of NPM Authorized Designee Date Subscribed and sworn to before me this date: Signature of Notary Public County Commission Expires American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Non-Participating Manufacturer NPM-2 Instructions Certification of Appointment of Agent for Service of Process General Information Specific Instructions Who must file this Certification? Part 1: Liability Year and Type of Certification Any Non-Participating Manufacturer (NPM) whose cigarettes or roll-your-own tobacco (RYO) were sold in Illinois during the preceding calendar year or who intend for their brands to be listed as compliant in the Illinois Directory of Compliant NPMs. • • • Who must appoint an Agent for Service of Process? • • Non-resident (out-of-state) and foreign NPMs that are not registered to do business in Illinois are required to continually engage, without interruption, an agent in this State for acceptance of service of process. Where an NPM’s products are sold in Illinois and the NPM fails to appoint an agent as required by Section 20 of the Tobacco Products Manufacturers’ Escrow Enforcement Act of 2003, it shall be deemed to appoint the Illinois Secretary of State as the agent on whom process may be served on its behalf. However, such appointment will not satisfy the condition precedent for having its brand families listed in the Directory of Compliant NPMs. Check appropriate liability year. You must submit a separate certification for each year. If “Other” is checked, enter liability year for which certification is being provided. Check whether this is an initial (manufacturer is not currently listed on the Illinois Directory), annual (due April 30, 2011 for 2010 sales) or supplemental (change of information provided to the Attorney General) certification. Part 2: Manufacturer Identification Provide your company name, address, and phone, fax, and FEIN numbers. Part 3: Manufacturer Status • • • If you are registered to do business in Illinois, ATTACH CERTIFICATION FROM THE ILLINOIS SECRETARY OF STATE and complete Part 5. If you are not registered to do business in Illinois, you must appoint an agent for service of process who is located within Illinois. ATTACH CURRENT PROOF OF APPOINTMENT AND AVAILABILITY OF AGENT. When is this Certification due? The annual certification must be filed with the Attorney General no later than April 30 of each year. An initial certification may be filed at any time. Part 4: Agent Appointed for Service of Process • Updates Provide contact name and company of Agent appointed for service of process. Provide their physical (street) address as well as mailing address, phone and fax numbers, e-mail address and availability. Provide a letter from the Agent acknowledging appointment for 2011. Availability of Agent: normal business hours during which the agent would be available at the address provided, for the purpose of service of process. If the NPM terminates the authority of an agent, the NPM shall notify the Attorney General at least 30 calendar days prior to the termination, and provide proof of the appointment of a new agent at least 5 calendar days prior to the termination. • If the agent terminates an agency appointment, the NPM shall notify the Attorney General of the termination within 5 calendar days of the termination and shall include proof of the appointment of a new agent. Part 5: Manufacturer Certification For Additional Forms and Information Phone (217) 785-8541 Fax (217) 524-4701 www.IllinoisAttorneyGeneral.gov (Click on Tobacco) • The authorized designee executing the certification must be an officer, principal, director or other authorized representative of the manufacturer. The authorized designee’s name and title must be legibly printed and the signature must be notarized. Mail original document, with attachments to: Office of the Attorney General Tobacco Enforcement Bureau 500 South Second Street Springfield IL 62706 Rev. 3/7/2011 American LegalNet, Inc. www.FormsWorkFlow.com