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Manufacturer Certification Form. This is a New Hampshire form and can be use in Office Of Attorney General Statewide.
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State of New Hampshire
Certification Pursuant to NH RSA 541-D
2007
GENERAL INFORMATION
Who is required to file this certification?
Any tobacco product manufacturer that intends to sell cigarettes and/or smokeless tobacco products within the state of
New Hampshire, whether directly or through any distributor, retailer, or similar intermediary.
ELECTRONIC FILING OPTION:
Certificates will be considered timely filed if sent by e-mail to
Maroney@gcglaw.com prior to the filing date of April 30, 2007. If you choose this option please label your cover e-mail
with your company name and the words “RSA 541-D Annual Certification 2007” in the subject line.
If an electronic filing is submitted, the fully executed hard copy must still be sent to the address above by no later
than May 15, 2006 to constitute a complete and timely filing.
This filing is in addition to, and does not supplant any filing obligations of non-participating manufacturers under
RSA 541-C. However, the RSA 541-C filing may be made in conjunction with this filing and will be considered
timely filed if received by this office by April 30, 2007.
Definitions:
(a) “Attorney General” means the Attorney General of the state of New Hampshire, 33 Capitol Street, Concord
New Hampshire 03301.
(b) “Brand Family” means all styles of Cigarettes sold under the same trade mark 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.
(c) “Brand Name” includes all products sold within any Brand Family, including without limitation, products
described by descriptors or modifiers such as “menthol,” “lights,” “kings,” and “100s.”
(d) “Cigarette” has the same meaning as in RSA 541-C:2, IV, and includes smokeless tobacco products.
(e) “Commissioner” means the Commissioner of the New Hampshire Department of Revenue.
(f) “Directory” means the listing of all Tobacco Product Manufacturers that have provided current and accurate
certifications conforming to the requirements of NH RSA 541-D and all Brand Families that are listed in such
certifications; except as provided by NH RSA 541-D.
(g) “Master Settlement Agreement” (or “MSA”) has the same meaning as in RSA 541-C:2, V.
(h) “Non-Participating Manufacturer” (or “NPM”) means any Tobacco Product Manufacturer that is not a
Participating Manufacturer.
(i) “Participating Manufacturer” has the meaning given that term in Section II(jj) of the Master Settlement
Agreement and all amendments thereto.
(j) “Qualified Escrow Fund” has the same meaning as that term is defined in RSA 541-C:2, VI.
(k) “Stamping Agent” means a person that is authorized to affix tax stamps to packages or other containers of
Cigarettes under RSA Ch. 78 or any person that is required to pay the tobacco tax imposed pursuant to RSA Ch.
78 on Cigarettes.
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(l) “Tobacco Product Manufacturer” has the same meaning as that term is defined in RSA 541-C:2, IX.
(m) “Units Sold” has the same meaning as that term is defined in RSA 541-C:2, X.
When is this certification due?
This certificate of compliance is to be filed on or before April 30, 2007.
ELECTRONIC FILING OPTION. Certificates will be considered timely filed if sent by e-mail to
Maroney@gcglaw.com prior to the filing date of April 30, 2007. However, if an electronic filing is submitted, the fully
executed hard copy must still be sent to the address above by no later than May 15, 2007 to constitute a compete and
timely filing. See full instructions for electronic filing at the end of the Certificate.
SPECIFIC INSTRUCTIONS:
Part 1:
Manufacturer's Identification. Identify the name, address, zip code or (for manufacturer’s located outside
the United States) local mail code, telephone, fax number and electronic mail address.
Part 2:
Certification of Status. State whether your company is a Participating Manufacturer or a Non-Participating
Manufacturer in compliance with all applicable n provisions of RSA 541-C.
Please note that the Certification Form was amended in 2006 to require that, if the submitting
company is not the actual manufacturer of the tobacco products for which it is submitting the
certification, it must identify the manufacturer and, as applicable, describe the relationship
between the submitting company and the manufacturer. If the submitting company has agreed by
contract or otherwise to assume escrow responsibility for a manufacturer, it must submit an
executed copy of any such agreement.
NO AGREEMENT TO ACCEPT ESCROW RESONSIBILITY WILL BE RECOGNIZED WITHOUT
SUBMISSION OF AN EXECUTED CONTRACT.
Part 3:
Sales Year. Identify the sales year during which the certification is filed.
Part 4:
Brand Family Identification: Identify by Brand Family and Brand Name all of the cigarettes that the
Tobacco Product Manufacturer HAS SOLD OR 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 and Brand Names. The Participating
Manufacturer shall update such list thirty (30) calendar days prior to any addition to or modification of its
Brand Families or Brand Names by executing and delivering a supplemental certification to the Attorney
General and Commissioner.
IF THIS IS A SUPPLEMENTAL ANNUAL CERTIFICATION, YOU MAY NOTE THAT FACT ON
THE CERTIFICATE AND SHOULD ONLY LIST NEW BRANDS WHICH YOU INTEND TO MARKET.
PLEASE REVIEW YOUR BRAND LISTING ON THE STATE’S CERTIFICATION DIRECTORY
(www.gcglaw.com/tobacco) TO ENSURE THAT ALL OF YOUR COMPANY’S BRANDS ARE
PROPERLY LISTED.
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A Non-Participating Manufacturer shall include in its certification (i) a list of all of its Brand Families and
Brand Names and the number of Units Sold for each Brand Family that were sold in the State during the
preceding calendar year, (ii) indicating, by an asterisk, any Brand Family and/or Brand Name 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, (iii) a list of all of its Brand Families and Brand Names that are being sold in the State at any
time during the current year, and (iv) identifying 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 (30) calendar days prior to any addition to or modification of its Brand Families by executing
and delivering a supplemental certification to the Attorney General and Commissioner.
Part 5:
Non-Participating Manufacturer Certification.
A. 1. Verify that the Non-Participating Manufacturer is registered to do business in New Hampshire.
PROVIDE A COPY OF A CERTIFICATE OF GOOD STANDING ISSUED BY THE OFFICE OF
THE NEW HAMPSHIRE SECRETARY OF STATE; OR
A. 2. If your company has not registered to do business in New Hampshire, verify that it has appointed an
agent for service of process and provided notice thereof as required by RSA 541-D. If no agent for service of
process is appointed, the New Hampshire Secretary of State will be deemed the company’s agent for service
of process.
IF THIS IS A SUPPLEMENTAL ANNUAL CERTIFICATION, AND THERE HAS BEEN NO
CHANGE IN THE INFORMATION REQUIRED IN SECTION A.2, SINCE THE LAST ANNUAL OR
ANY SUPPLEMENTAL CERTIFICATION, PLEASE RESPOND BY CHECKING THE BOX LABELED
“NO CHANGE SINCE PRIOR CERTIFICATION”
B. Identify (i) the name, address and telephone number of the financial institution where the NonParticipating Manufacturer has established a Qualified Escrow Fund pursuant to RSA 541-C; (ii) the
account number of such Qualified Escrow Fund and any sub-account number for New Hampshire.
IF THIS IS A SUPPLEMENTAL ANNUAL CERTIFICATION, AND THERE HAS BEEN NO
CHANGE IN THE INFORMATION REQUIRED IN SECTION B SINCE THE LAST ANNUAL OR ANY
SUPPLEMENTAL CERTIFICATION, PLEASE RESPOND BY CHECKING THE BOX LABELED “NO
CHANGE SINCE PRIOR CERTIFICATION.”
C. Identify (i) the amount such Non-Participating Manufacturer placed in such fund for Cigarettes sold in the
State during the preceding calendar year, (ii) the date and amount of each such deposit; and (iii) the
amount and date of any withdrawal or transfer of funds the Non-Participating Manufacturer made at any
time from such fund or from any other Qualified Escrow Fund.
IF THIS IS A SUPPLEMENTAL ANNUAL CERTIFICATION, YOU NEED ONLY LIST DEPOSITS
OR WITHDRAWALS MADE SINCE THE DATE OF YOUR COMPANY’S LAST ANNUAL
CERTIFICATION.
Part 6:
Signature: The person executing the Certification must do so before an authorized notary.
Both Participating and Non-Participating Manufacturers must sign this document in the presence of a Notary
or such similar official in the company’s home nation.
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If you have questions regarding this form, kindly direct them to:
Office of the Attorney General
Tobacco Compliance Project
Or, in writing to
c/o Walter L. Maroney, Esq.
Gallagher, Callahan & Gartrell, P.C.
214 N. Main Street
P.O. Box 1415
Concord NH 03302-1415
Assistant Attorney General David Rienzo
Office of the Attorney General
Tobacco Compliance Project
33 Capitol Street
Concord, NH 03301
(603)-228-1181
(800)-528-1181
FAX (603)-228-7588
e-mail: maroney@gcglaw.com
Form: www.gcglaw.com/tobacco
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State of New Hampshire
Manufacturer Certification
Pursuant to NH RSA 541-D
APRIL 30, 2007
_
SUPPLEMENTAL CERTIFICATION
_
This is an
INITIAL CERTIFICATION
Part 1:
Tobacco Product Manufacturer Identification
Company:
____________________________________________________________________________________
Address:
____________________________________________________________________________________
City
______________________________________
State
______________________________________
Zip code
______________________________________
Country________________________________
Or other mail code: ________________________________________________________________________________
Phone:
______________________________________
Email:
FAX _________________________________
______________________________________
Name/Title of Person Completing Report: _______________________________________________________________
Part 2:
Certification of Status
The Tobacco Product Manufacturer identified above is, as of the date of this Certification:
(Choose One)
________
A Participating Manufacturer under the Tobacco Master Settlement Agreement.
________
A Non-Participating Tobacco Product Manufacturer in full compliance with RSA 541-C.
__________
A First Importer of Cigarettes not intended For Distribution In the United States, and which is in full
compliance with RSA 541-C.
IF YOU CHECK THIS OPTION, PROVIDE ALL INFORMATION REQUIRED IN PART 1 FOR
THE MANUFACTURER OF EACH BRAND FAMILY TO WHICH THIS OPTION APPLIES.
(add additional sheets if necessary)
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__________
A person or entity which has accepted responsibility for compliance with RSA 541-C under a written
contract with the Manufacturer or Fabricator of the cigarettes for which this Certification is submitted.
IF YOU CHECK THIS OPTION,
(1) PROVIDE ALL INFORMATION REQUIRED IN PART 1 FOR THE MANUFACTURER
OF EACH BRAND FAMILY TO WHICH THIS OPTION APPLIES;
(2) DESCRIBE THE RELATIONSHIP BETWEEN YOUR COMPANY AND THE
MANUFACTURER OF EACH BRAND FAMILY TO WHICH THIS OPTION APPLIES;
and
(3) PROVIDE A COPY OF AN EXECUTED CONTRACT BETWEEN YOUR COMPANY.
Add additional pages if necessary.
Part 3:
Sales Year
Year of Sales for this Certificate of Compliance is: 2007.
Part 4:
Brand Family Identification (Attach additional Sheets if Necessary)
Participating Manufacturers are only required to fill out Sections A and B of this Part. If this is a
Supplemental Annual Certification and there has been no change in the Brand Families and Brand
Names Listed in the most recent Annual or Supplemental Certifications submitted by your company,
indicate this fact by marking the check box below.
PARTICIPTING MANUFACTURERS:
_
NO CHANGE SINCE PRIOR CERTIFICATION
NON-PARTICIPATING MANUFACTURES must fill out Sections A, B, C, and D and E of this Part.
_
NO CHANGE SINCE PRIOR CERTIFICATION
A. Brand
Families Sold in
State in 20061
B. Brand Names
C. Total Units D. Names of New
E. Brand Names
sold in 2006 Brand Families, (New Brand Families)
By Brand
If Any, To Be
Family
Sold In State in
2007
Add additional pages if necessary
1
Indicate with and asterisk (*) those Brand Families and/or Brand Names that will not be sold in 2007.
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Part 5:
Non-Participating Manufacturer Certification
A.
1.
Registered to Do Business
State whether your Company is currently registered to do business in New Hampshire with the Office of
the New Hampshire Secretary of State.
Yes _________
No _________
If yes, state the date of registration
______________________
Describe the form of Organization (e.g., corporation, limited liability company, partnership, etc.)
__________________________________
Is your company registered as a Foreign ___ or Domestic ___ business entity?
PROVIDE A COPY OF A CERTIFICATE OF GOOD STANDING ISSUED BY THE OFFICE OF
THE NEW HAMPSHIRE SECRETARY OF STATE.
2.
Agent for Service of Process
_
NO CHANGE SINCE PRIOR CERTIFICATION
Agent Name:
____________________________________________________________________________________
Company:
____________________________________________________________________________________
Address:
____________________________________________________________________________________
Address:
____________________________________________________________________________________
Phone:
_________________________________________
E-mail:
_________________________________________
FAX __________________________________
Has the Agent for Service of Process been approved by the Attorney General?
By Whom:
___________________________________________________
_______________________________
Approval Date:
_______________
C. Qualified Escrow Fund – Financial Institution
_
NO CHANGE SINCE PRIOR CERTIFICATION
Name of Institution:
______________________________________________________________________________
Address:
______________________________________________________________________________
Representative Name: ________________________________________ Phone:_______________________________
Escrow Acct No:
________________________________________ State Account No: _____________________
Has the Qualified Escrow Agreement been approved by the Attorney General?
By Whom:
___________________________________________________
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RSA 541-D Certification Form
(Manufacturers)
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Approval Date:
_______________
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D. Escrow Deposit/Withdrawal History for New Hampshire
IF THIS IS A SUPPLEMENTAL ANNUAL CERTIFICATION ONLY DEPOSITS AND WITHDRAWALS
MADE SINCE THE LAST ANNUAL CERTIFICATION NEED BE LISTED.
Date
Part 6:
Deposit
Withdrawal
Balance
Signature
Under penalty of perjury, I state that the information contained in this Certification is true and accurate and that I am
authorized to sign this certification, to make all representations, and to make all appointments contained herein.
Name of Authorized Agent:
________________________________________
Signature of Authorized Agent: ________________________________________
Title: _______________________
Date: _______________________
Subscribed and sworn to before me on this _____day of _______________, 200___ by __________________________,
known to me or having satisfactorily demonstrated his/her identity.
Signature of Notary Public: _____________________________________ City or County of_____________________
My Commission expires: _______________________________________
Mail the completed certificate of compliance to:
Office of the Attorney General
Tobacco Compliance Project
c/o Gallagher, Callahan & Gartrell, P.C.
214 N. Main Street
P.O. Box 1415
Concord NH 03302-1415
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State of New Hampshire
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