Tobacco Product Manufacturer (TPM) Certification Form. This is a Massachusetts form and can be use in Attorney General Statewide.
Tags: Tobacco Product Manufacturer (TPM) Certification, Massachusetts Statewide, Attorney General
COMMONWEALTH OF MASSACHUSETTS TOBACCO PRODUCT MANUFACTURER (TPM) CERTIFICATION (M.G.L. c. 94F) (February 2011) Please type, or print legibly in permanent blue ink. Select one (see instructions): Initial TPM Certification Annual TPM Certification Supplemental TPM Certification PART I: MANUFACTURER INFORMATION Company Name: Street Address: Mailing Address: Website: Contact Person: Telephone: Fax: Email: Manufacturing Address: Name of Factory Manager(s): Telephone: Fax: Manufacturer's Federal Taxpayer ID Number: TTB Manufacturer or Importer Permit Number: Exp. Name and Title of Person Completing this Certification: Telephone: Fax: Email: TPM Certification Page 1 of 6 Rev. 02/2011 American LegalNet, Inc. www.FormsWorkFlow.com PART II: PM/NPM Status 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 (“NPM”) 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 INDENTIFICATION As of January 1, 2008, cigarettes must be certified as fire safe under M.G.L. c. 64C before they can be sold in Massachusetts or listed on the TPM Directory. All TPMs must provide documentation reflecting this certification. A. PARTICIPATING MANUFACTURERS (see Instructions) Brand Family (use additional sheets if necessary) By listing these Brand Families, the 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. B. NON-PARTICIPATING MANUFACTURERS (see Instructions) Brand Family and Additional Information (see Instructions) Units Sold in MA (2010) Cigarette Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette Use additional sheets if necessary. RYO RYO Total from additional sheets: 0.09 oz. of RYO constitutes one unit. TOTAL UNITS SOLD (2010): x $0.0274350 = Escrow Deposit for Sales in 2010 TPM Certification Page 2 of 6 Rev. 02/2011 American LegalNet, Inc. www.FormsWorkFlow.com By listing these Brand Families, the Non-Participating Manufacturer affirms that they are deemed to be its Cigarettes for purposes of M.G.L. c. 94E. NON-PARTICIPATING MANUFACTURERS must produce documentation such as sales invoices to substantiate the reported RYO units sold in Massachusetts during 2010. This documentation must identify the entity (wholesaler/distributor/retailer) by name and address that the RYO was sold to, according to brand name and 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). On a separate sheet of paper, for each Brand Family: 1. Attach a list of cigarette brand styles that have been certified as fire safe under Chapter 64C. 2. Provide the address(es) where the Brand Family was manufactured, if different from the addresses provided in Part I. Check here if not applicable 3. State the name and address of any other manufacturer (including prior manufacturer) of the Brand Family, and the applicable time period(s). Check here if not applicable 4. State the name and address of the trademark holder for the Brand Family, if it is not the Company. Check here if not applicable 5. State the name and address of the person, if it was not the Company, who made the most recent filings of the following: health warning rotation plan (15 U.S.C. §1333(c); 19 U.S.C. §1681a(a)(3)); ingredient list for the Brand Family (15 U.S.C. §1335a(a); 19 U.S.C. §1681a(1)); and nicotine yield report (M.G.L. c. 94, §307B(b)). Check here if not applicable PART IV: SUPPLEMENTAL DOCUMENTATION (include as separate attachments) A. Provide a sample of the packaging for each brand family, unless you have previously provided packaging samples which have not changed. An electronic representation (e.g., CD or DVD) is acceptable. Check here if you have previously provided packaging samples and the packaging has not changed in any manner. Date: Please note that a Supplemental TPM Certification is required for any packaging changes subsequent to the date of this Certification. B. For each brand of cigarettes listed above, provide a copy of the current Federal Trade Commission approval letter for the health warning rotation plan. C. For each brand of cigarettes listed above, provide a copy of the current Center for Disease Control and Prevention ingredient-listing compliance letter(s). D. As of January 1, 2008, all cigarettes stamped for sale in Massachusetts must be certified as “Fire Standard Compliant.” Provide a copy of the State Fire Marshal's approval letter listing each cigarette brand style certified as Fire Standard Compliant for sale in Massachusetts. E. For each brand family listed in Part III, indicate the owner of the trademark. If it is different from the certifying Company, indicate if the owner is an Affiliate of the Company. If the owner is not an Affiliate, provide contact information for the trademark owner, and a copy of all manufacturing agreements or other documents granting the certifying Company the right to manufacture the cigarettes. F. Provide a copy of the Company's TTB Tobacco Manufacturer and/or Tobacco Importer Permit(s) TPM Certification Page 3 of 6 Rev. 02/2011 American LegalNet, Inc. www.FormsWorkFlow.com G. For each brand family, provide proof of submission(s) to the FDA of the disclosure of tobacco product ingredients, as required by § 904 of the Federal Food, Drug and Cosmetic Act (FFDCA). H. Provide a notarized statement that the brand styles listed above are not subject to the ban, effective September 22, 2009, by the FFDCA (as amended by the Family Smoking Prevention and Tobacco Control Act), on constituents and additives, including artificial or natural flavors other than tobacco or menthol, or herbs or spices, that are characterizing flavors of tobacco products or their smoke. I. Provide a copy of your registration and all monthly shipment reports filed with the Massachusetts Department of Revenue, as required by the federal Prevent All Cigarette Trafficking (PACT) Act, 15 U.S.C. §§ 375 et seq. If you have failed to register and report as required by PACT and/or cannot provide the requested documentation, please provide a detailed explanation on a separate sheet. PART V: ESCROW ACCOUNT INFORMATION (NPMs only: PMs skip to Part VII) Identify the financial institution where the Company has established and maintains an escrow account for purposes of M.G.L. c. 94E: 1. Name: Address: Website: Contact Person: Telephone: Fax: Email: Account No.: MA Sub-Account No.: Date of Escrow Agreement: Dates of All Amendments to Escrow Agreement: SUBMIT A COPY OF YOUR CURRENT ESCROW AGREEMENT AND ALL AMENDMENTS. Have you previously submitted the current Escrow Agreement and all amendments to the Massachusetts Attorney General? Yes No Has the Attorney General approved the Escrow Agreement and all amendments? Yes TPM Certification No Page 4 of 6 Rev. 02/2011 American LegalNet, Inc. www.FormsWorkFlow.com 2. Deposit/Withdrawal History for Massachusetts Sub-Account: Date: Deposit1 Withdrawal2 Balance NOTE: You must attach to this TPM Certification a copy of a receipt or other confirmation from the financial institution for each deposit (or state that the receipt previously filed was with a TPM Certification) and for the current balance of the Massachusetts Sub-Account. PART VI: AGENT FOR SERVICE OF PROCESS (NPMs only) The Company (select one): is registered to do business in Massachusetts. (attach a copy of most recent registration filing) has appoint an agent in Massachusetts for service of process. has attached an executed Notice of Appointment. has previously filed a Notice of Appointment that remains in effect. Date of Notice: PART VII: NPM COMPANY AND COMPLIANCE INFORMATION (NPMs only) 1. Stampers/Wholesalers. On an attached sheet of paper labeled “Stampers/Wholesalers,” provide the name and address of each stamper that affixes the Massachusetts excise stamp to your Cigarettes (for RYO, the name and address of each wholesaler/distributor that re-sells the product to Massachusetts retailers, and the name and address of each retailer in Massachusetts that you sell directly to). Be sure to include any stampers/wholesalers that may be located outside of Massachusetts. 2. Has any State brought a civil enforcement action against the Company or an Affiliate (see definitions) for an alleged failure to comply with the NPM escrow statute of any State (e.g., M.G.L. c. 94E) or for an alleged failure to comply with the NPM “complementary legislation” of any State (e.g., M.G.L. c. 94F)? Yes No If “Yes”: on an attached sheet of paper labeled “Enforcement Actions,” provide the title of the action, the court in which it was brought, and whether a judgment was entered. 3. Has any State denied the application of the Company or an Affiliate for listing any brand in a Directory under its NPM “complementary legislation” (e.g., M.G.L. c. 94F)? Yes No If “Yes”: on an attached sheet of paper labeled “Directory,” identify the company, the Brand Families, and the State. 1. The escrow amount due each year is calculated by multiplying the number of Units Sold in the previous year by the Base Amount times the Inflation Adjustment (see Exhibit C of the tobacco Master Settlement Agreement): e.g., by $0.0274350 for sales in 2010. 2. Withdrawals are permitted only as authorized by M.G.L. c. 94E, §2(b)(2). TPM Certification Page 5 of 6 Rev. 02/2011 American LegalNet, Inc. www.FormsWorkFlow.com PART VIII: DECLARATION, ACKNOWLEDGMENT, AND SIGNATURE Under penalties of perjury, the undersigned authorized officer of the Company states that: 1. I am an officer of the Company, and I am authorized to execute this TPM Certification on its behalf. 2. I have read the Instructions for this TPM Certification. I understand that any misrepresentation may be grounds for not including the Company on the TPM Directory. 3. I understand that the Attorney General may require additional information and/or documentation with regard to this TPM Certification. I understand that failure to provide additional information and/or documentation may be grounds for not including the Company on the TPM Directory. 4. I have examined this TPM Certification, as well as the attachments and other accompanying documents, and, to the best of my knowledge and belief, they are true, correct, and complete. 5. The Company will immediately notify the Attorney General in the event that the submitted information and documents are no longer accurate or complete. 6. The Company executes this TPM Certification pursuant to M.G.L. c. 94F, in order to sell its Cigarettes in Massachusetts, and specifically consents to the jurisdiction of the Superior Court of Massachusetts, and waives any objection to such jurisdiction for purposes of any enforcement action that may be brought by the Attorney General under M.G.L. c. 94E or M.G.L. c. 94F with respect to the TPM Certification or any Cigarettes sold in Massachusetts, or otherwise failing to comply with either M.G.L. c. 94E or M.G.L. c. 94F. 7. The Company waives any sovereign immunity defense that may apply to enforcement actions that may be brought by the Attorney General under M.G.L. c. 94E or M.G.L. c. 94F with respect to the TPM Certification or any Cigarettes sold in Massachusetts. Typed or Printed Name of Authorized Officer Title Signature of Authorized Officer Date Subscribed and sworn to before me on this date: Signature of Notary Public: Country and City or County of:: My Commission Expires: Please mail this TPM Certification and all supporting documentation to both: Original: Tobacco Enforcement Office of the Attorney General Commonwealth of Massachusetts One Ashburton Place Boston, MA 02108-1598 TPM Certification Copy: TPM Directory Rulings and Regulations Bureau Department of Revenue Commonwealth of Massachusetts P.O. Box 9566 Boston, MA 02114-9566 Page 6 of 6 Rev. 02/2011 American LegalNet, Inc. www.FormsWorkFlow.com