Tobacco Product Manufacturer (TPM) Certification Form. This is a Massachusetts form and can be use in Attorney General Statewide.
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COMMONWEALTH OF MASSACHUSETTS TOBACCO PRODUCT MANUFACTURER (TPM) CERTIFICATION (M.G.L. c. 94F) (February 2018) Please type, or print legibly in permanent blue ink. Required attachments may be submitted on CD-ROM or be email to MSA@state.ma.us. Select one (see instructions): Initial TPM Certification Annual TPM Certification Supplemental TPM CertificationPART I: MANUFACTURER INFORMATION (All TPMs) Company Name: Street Address: Mailing Address: Website: Contact Person: Telephone: Fax: Email: Address of Manufacturing Facility: Name of Factory Manager(s): Telephone: Fax: Manufacturer's Federal Taxpayer ID Number: TTB Manufacturer or Importer Permit Number: Expiration: Name and Title of Person Completing this Certification: Email: Fax: Telephone:TPM CertificationPage 1 of 6Rev. 02/2018 American LegalNet, Inc. www.FormsWorkFlow.com TPM CertificationPage 2 of 6Rev. 02/2018PART II: PM/NPM Status (All TPMs)The undersigned certifies that, as of this date, the above-named manufacturer is (select one): a Participating Manufacturer ("PM") under the MSA a Non-Participating Manufacturer (223NPM224) in full compliance with M.G.L. c. 94E and M.G.L. c. 94F, and implementing regulations, and has made all required deposits into a qualified escrow fund approved by the Attorney General for sales in Massachusetts since June 29, 2000.PART III: BRAND FAMILY and BRAND STYLE INDENTIFICATION A. ALL MANUFACTURERS (see Instructions) 1. For Annual and Initial TPM Certification Manufacturers seeking an annual certification must download, complete, and submit by email to MSA@state.ma.us or on CD-ROM the Excel spreadsheet made available to you listing cigarette Brand Styles and RYO Brand Families you manufacture currently on the Massachusetts Tobacco Product Directory. Manufacturers seeking an initial certification of its Brand Styles should download, complete, and submit the Product Certification Template. All spreadsheets are available for you to download at www.mass.gov/ago/tobacco . Following the instructions on that spreadsheet, please (a) indicate whether a listed Brand Style should remain on the Massachusetts Directory; (b) indicate whether a Brand Style should be deleted from the Massachusetts Directory because you discontinued it and it is no longer in the stream of commerce, or, if you no longer wish to certify it for sale in Massachusetts; (c) add any Brand Styles and Brand Families you are seeking to certify for sale in Massachusetts through this certification. Include for each cigarette Brand Style the 12 or 13 digit UPCs appearing on the carton; and/or (d) 223redline224 any changes to the Brand Styles and Brand Families (e.g. change in Brand Style Name, change in Packaging Type, etc.). You must notify the Attorney General and Department of Revenue at least 30 days in advance of any changes in the UPCs. Products with unreported UPCs will not be able to be sold in Massachusetts. If you manufacture any other Brand Families that are not sold in Massachusetts, please attach a separate list of these additional Brand Families you manufacture. 2. For Supplemental TPM Certification Manufacturers submitting a Supplemental TPM Certification to add, delete, or change a Brand Style should download, complete, and submit the Product Certification Template for the Brand Style(s) the manufacturer seeks to add, delete, or change. Product Certification Template is available to download at www.mass.gov/ago/tobacco . By listing these Brand Styles and Brand Families in an Annual, Initial, and/or Supplemental TPM Certification a Participating Manufacturer affirms that they are deemed to be 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. By listing these Brand Styles and Brand Families, the Non-Participating Manufacturer affirms that they are deemed to be its Cigarettes for purposes of M.G.L. c. 94E.B. NON-PARTICIPATING MANUFACTURERS (see Instructions) 1. State the quantity of Units Sold for each Brand Family for which you are the TPM. Brand Family Units Sold in MA (2017) Cigarette RYO RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette Use additional sheets if necessary. Total from additional sheets:0.09 oz. of RYO constitutes one unit. TOTAL UNITS SOLD (2017): x $0.0337416 = Escrow Deposit for Sales in 2017 American LegalNet, Inc. www.FormsWorkFlow.com TPM CertificationPage 3 of 6Rev. 02/20182. NPM Supplemental Documentation NPMs must attach the following as exhibits to this Certification: a. Attach documentation such as sales invoices to substantiate the reported RYO units sold in Massachusetts during 2017. This documentation must identify the name and address of the entity (wholesaler/distributor/retailer/consumer) to which the RYO was sold, and identify the brand name and quantity of units sold. Please note that this documentation is required for all RYO sold in Massachusetts, regardless of whether it is a direct sale or through a distributor (whether or not located in Massachusetts). b. State the address(es) where each Brand Family was manufactured, if different from the addresses provided in Part I. c. State the name and address of any other manufacturer (including prior manufacturer) of each Brand Family, and the applicable time period(s). Check here if not applicable Check here if not applicablePART IV: ALL TPMs SUPPLEMENTAL DOCUMENTATIONA. Provide a sample of the packaging for each Brand Style, unless you have previously provided packaging samples which have not changed. An electronic representation (e.g., CD or DVD) is preferred. Please note that a Supplemental TPM Certification is required for any packaging changes subsequent to the date of this Certification. B. For each Brand Style of cigarettes listed in Part III.A., provide a copy of the current Federal Trade Commission approval letter for the health warning rotation plan. Not applicable to RYO. C. For each Brand Style of cigarettes listed in Part III.A., provide a copy of the current Center for Disease Control and Prevention ingredient-listing compliance letter(s) pursuant to 15 U.S.C. 2471335a(a); 19 U.S.C. 2471681a(1). Not applicable to RYO. D. For each Brand Style of cigarettes and/or RYO listed in Part III.A., provide proof of the submittal to Center for Tobacco Products (223CTP224) of the disclosure of tobacco product ingredients that was due by June 2010 pursuant to 21 U.S.C.A. 247 387d. Not applicable to RYO. E. Has the Massachusetts State Fire Marshal provided approval letters to the Manufacturer that all Brand Styles of cigarettes listed in Part III.A. are certified as Fire Standard Compliant? If the Massachusetts State Fire Marshal has not certified any Brand Style listed in Part III.A. as Fire Standard Compliant, explain why the Brand Style has not been certified. Provide any documentation explaining why the Massachusetts Fire Marshall has not certified any Brand Style listed in Part III.A. as Fire Standard Compliant (e.g. manufacturer's application to the Massachusetts State Fire Marshal seeking Fire Standard Compliant certification for Brand Style(s)). NOTE all Brand Styles of cigarettes the Manufacturer lists in Part III.A. will be compared to the Massachusetts State Fire Marshall's database of Brand Styles that are certified as Fire Standard Compliant. Not applicable to RYO. F. For each Brand Family listed in Part III.A., state the name and address of the trademark holder and if different from the certifying Company, state whether the holder is an Affiliate of the Company. If the holder is not an Affiliate, provide contact information for the trademark holder, and a copy of all manufacturing agreements or other documents granting the certifying Company the right to manufacture the cigarettes or RYO. G. Provide a copy of the Company's TTB Tobacco Manufacturer and/or Tobacco Importer Permit(s). H. Provide a notarized statement that the Brand Styles listed in Part III.A. do not contain as a constituent or additive, any artificial or natural flavors (other than tobacco or menthol) or any herb or spice, that is a characterizing flavor of the tobacco products