STATE OF VERMONT OFFICE OF THE ATTORNEY GENERAL TOBACCO PRODUCT MANUFACTURER CERTIFICATION PURSUANT TO 33 V.S.A. CHAPTER 19, SUBCHAPTER 1-B GENERAL INFORMATION Who is required to file this certification? Any tobacco product manufacturer that sells or intends to sell cigarettes within the state of Vermont, whether directly or through any distributor, retailer, or similar intermediary, is required to file this certification. This Tobacco Product Manufacturers Certification is in addition to any Quarterly or Annual Certificate of Compliance that may be required of Nonparticipating Tobacco Product Manufacturers pursuant to 33 V.S.A. Chapter 19, subchapters 1-A and 1-B. When is this Certification due? A TPM Certification must be received on or before April 30th each year with figures provided for the previous sales year. The current TPM certification form will be posted on the Attorney General’s website after February 1st of each year. Definitions: a) "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 a 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. b) "Cigarette" has the same meaning as in 33 V.S.A. §1913(4). c) "Directory" means the listing of all Tobacco Product Manufacturers that have provided current and accurate certifications conforming to the requirements of 33 V.S.A., Chapter 19, Subchapter 1-B, and all Brand Families that are listed in such certifications; except as provided by 33 V.S.A. §1918. d) "Master Settlement Agreement" has the same meaning as in 33 V.S.A. §1913(5). e) "Non-Participating Manufacturer" means any Tobacco Product Manufacturer that is not a Participating Manufacturer. f) "Participating Manufacturer" has the meaning given that term in Section II (jj) of the Master Settlement Agreement and all amendments thereto. g) "Qualified Escrow Fund" has the same meaning as that term is defined in 33 V.S.A. §1913(6). h) "Stamping Agent" (33 V.S.A. §1916(10)) means a person or entity that is required to secure a license pursuant to 32 V.S.A. §7731 or that is required to pay a tax on cigarettes imposed pursuant to 32 V.S.A., Chapter 205. i) "Tobacco Product Manufacturer" has the same meaning as that term is defined in 33 V.S.A. §1913(9). j) "Units Sold" has the same meaning as that term is defined in 33 V.S.A. §1913(10). American LegalNet, Inc. www.FormsWorkFlow.com SPECIFIC INSTRUCTIONS: Part 1: Manufacturer's Identification. Identify the name, physical address, mailing address, phone and fax numbers, email address and name and title of person completing report. Identify the name, physical address, phone and name of plant manager of the manufacturing plant if fabrication is done at another location. Part 2: Sales Year. The sales year is the immediately preceding calendar year. Part 3: Participating Manufacturer Brand Family Identification: (To be completed by Participating Manufacturers only). Identify by Brand Family and Brand Style all of the cigarettes and “roll-your-own” that the Tobacco Product Manufacturer sold in Vermont in the Sales Year. The Participating Manufacturer must include a list of its Brand Families. The Participating Manufacturer is required to update this list thirty calendar days prior to any addition to or modification of its Brand Families by executing and delivering a supplemental certification to the Attorney General. Part 4: Non-Participating Manufacturer Brand Identification (To be completed by Non-Participating Manufacturers only). NPMs must indicate one or more distributors licensed to sell its products in Vermont (“Stamping Agents”). For the purposes of Part 4 of this certification, distributors must have purchased the NPM’s product in the preceding year, or have indicated a commitment to purchase from the NPM within six months of the date of the certification. NPMs shall also include: (i) a list of all of its Brand Families and Brand Styles sold in Vermont in the Sales Year, (ii) the number of Units Sold of each product, to each distributor, during the Sales Year, (iii) the number of Units Sold in Vermont during the first quarter of the current calendar year, and (iv) the name and address of any other current or previous manufacturer of the listed Brand Families. The Non-Participating Manufacturer is required to update its Brand Family List thirty calendar days prior to any addition to or modification of it Brand Families by executing and delivering a supplemental certification to the Attorney General. Part 5: Modifications to the Vermont Directory (To be completed by Participating and Non-Participating Manufacturers). Identify by Brand Family and Brand Style all of the cigarettes that the Tobacco Product Manufacturer intends to sell and wants listed in the Vermont Directory for the next year. NOTE: Tobacco products not listed in the Vermont Directory are not legal for sale in Vermont. Cigarettes must also be separately certified as “Fire-Safe” to be legal for sale in Vermont under 20 V.S.A. §2757. Bidis may not be sold in Vermont. Part 6: Non-Participating Manufacturer Certification A. Verify that the Nonparticipating Manufacturer is registered to do business in Vermont or has appointed an agent for service of process and provided notice thereof as required by 33 V.S.A § 1920. NOTE: If agent has been appointed for purposes of this Certification, current proof of appointment and acceptance of appointment for a period of at least one year from certification date must accompany this Certification. B. Identify (i) the name, address, phone and fax numbers of the financial institution where the Nonparticipating Manufacturer has established a Qualified Escrow Fund pursuant to 33 V.S.A. §1914(2); (ii) the account number of such Qualified Escrow Fund and any sub-account number for Vermont; and (iii) the representative of the financial institution who administers the account. C. Identify (i) the amount such Nonparticipating Manufacturer placed in its Qualified Escrow Fund for Cigarettes sold in Vermont during the preceding calendar year, the date and amount of each such deposit; and (ii) the amount and date of any withdrawal or transfer of funds the Nonparticipating Manufacturer made at any time from such Qualified Escrow Fund. Part 7: Execution by Authorized Designees. The person executing the Certification must be an officer or director of the Tobacco Product Manufacturer identified in Part 1. The Designee's name and title must be printed and the Certification must be executed in the presence of an authorized notary. American LegalNet, Inc. www.FormsWorkFlow.com Tobacco Enforcement Unit Office of the Attorney General of Vermont 109 State Street Montpelier, Vermont 05609-1001 tobacco@atg.state.vt.us TOBACCO PRODUCT MANUFACTURERS CERTIFICATION PURSUANT TO 33 V.S.A. CHAPTER 19, SUBCHAPTER 1-B Part 1: Tobacco Product Manufacturer Identification Name of Company: ________________________________________________________________________ Physical Address (street address only, no post office box): _________________________________________ Mailing Address (if different from above): ______________________________________________________ ________________________________________________________________________________________ Phone: ____________________________________ Fax: _____________________________________________ Email: ________________________________________ Name/Title of Person Completing Report: ______________________________________________________ Manufacturing Plant Name and Physical Address (if different from above): ______________________________________________________ Plant Phone: ________________________ Name of Plant Manager:___________________________________________________ The undersigned certifies that, as of the date of this Certification, the above-named Tobacco Product Manufacturer is: (initial one) _________ A Participating Manufacturer in full compliance with the Tobacco Master Settlement Agreement _________ A Nonparticipating Tobacco Product Manufacturer in full compliance with 33 V.S.A. Chapter 19, Subchapters 1-A and 1-B. Part 2: Sales Year TPM Certification for Vermont Sales in: 2010 1 American LegalNet, Inc. www.FormsWorkFlow.com Part 3: PM Brand Identification (To be completed by Participating Manufacturers only) Brand Style Brand Family* (Indicate whether Cigarette or Roll-your-own) *By listing a Brand Family in its Certification, the Participating Manufacturer affirms that the Brand Family is its cigarettes for the purpose of calculating payments under the Master Settlement Agreement for the Sales Year, in the volume and shares determined pursuant to the Master Settlement Agreement. Nothing in this Certification shall limit or otherwise affect the State’s right to maintain that a Brand Family constitutes cigarettes of a different tobacco product manufacturer for purposes of calculating payment under the Master Settlement Agreement. Part 4: Non-Participating Manufacturer Brand Identification (To be completed by Non-Participating Manufacturers only) BRAND FAMILY BRAND STYLE DISTRIBUTOR UNITS SOLD (Indicate whether LICENSED TO SELL IN SALES YEAR Cigarette or VERMONT (Sticks or RYO Roll-your-own) (“Stamping Agent”) equivalent) UNITS SOLD CURRENT YEAR (Sticks or RYO equivalent) OTHER MANUFACTURER** (name & address) ** Identify other manufacturers, including any other current or previous fabricators of any Brand Families or Brand Styles listed on this Certification. 2 American LegalNet, Inc. www.FormsWorkFlow.com Part 5: Modifications to the Vermont Directory (To be completed by Participating and Non-Participating Manufacturers) Brands requested for listing in Vermont Directory: □ Same as above □ To be added: □ To be deleted: Part 6: Non-Participating Manufacturer Certification (To be completed by Non-Participating Manufacturers only) A. Registered Agent / Approved Agent for service of process The Tobacco Product Manufacturer identified above, as of the date of this Certification, certifies that it: (initial one) ______ Is registered to do business in Vermont with the Vermont Secretary of State ______ Has appointed a Vermont agent for service of process in the State of Vermont as identified below, and has submitted to the Attorney General: 1. Proof of the appointment, effective for at least one year from the date of this Certification, and 2. The agent’s acceptance of the appointment Agent Name: ____________________________________________________________________________ Company: _______________________________________________________________________________ Address: ________________________________________________________________________________ Phone: __________________________________ FAX: __________________________________________ Email:_____________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com B. Qualified Escrow Fund ─ Financial Institution Name of Institution: __________________________________________________________________________ Address: ____________________________________________________________________________________ Representative Name: _________________________________________________________________________ Phone: ______________________________________ FAX: ___________________________________________ Escrow Acct No: ______________________________ Escrow Agreement Dated: ________________________ State Account No: ____________________________________ (NOTE: A copy of the most recent version of the Escrow Agreement governing the Fund must be on file with the Attorney General, or should be submitted with this Certification.) C. Escrow Deposit/Withdrawal History for Vermont Date *** Deposit Withdrawal*** Balance Withdrawals must comply with 33 V.S.A. §1914(b). Verification of compliance must be provided. (Initial certification should include a complete history; annual certifications thereafter should include only account deposits and withdrawals not previously reported.) Part 7: Execution by Authorized Designee Under penalty of perjury, I certify and declare that all of the statements and information contained in this Certification, including any accompanying statements or attachments hereto, are true, correct, accurate and complete, and that I am an officer or director of the Tobacco Product Manufacturer making this Certification and am a person authorized to bind the Tobacco Product Manufacturer either under the laws of the State of Vermont or the jurisdiction where the manufacturer resides or is organized. I further certify that the Tobacco Product Manufacturer hereby submits itself to the jurisdiction of the courts of Vermont for purposes of all litigation arising out of this Certification or the sale of 4 American LegalNet, Inc. www.FormsWorkFlow.com tobacco products in Vermont. This TPM shall sell tobacco products only in compliance with all applicable provisions of federal and Vermont laws, rules, and regulations, including, but not limited to: 33 V.S.A. §§ 1912–24 (Qualifying Statute and Complementary Legislation), 20 V.S.A. §§ 2756– 57 (Reduced Ignition Propensity Cigarettes) and 7 V.S.A. § 1010 (Ban on shipping tobacco products into Vermont to anyone other than licensed wholesalers, retailers and distributors and internet sales ban), the Family Smoking Prevention and Tobacco Control Act and the PACT Act. I understand that the Attorney General may require additional information and/or documentation to determine if the Tobacco Product Manufacturer qualifies for listing in the Vermont Tobacco Directory and to determine that the assurances herein are true, correct, and complete; I agree to provide such information upon request, and I understand that failure to do so may constitute grounds for exclusion from the Vermont Tobacco Directory. Designee (Print Name): __________________________________________________________________ Title: ________________________________________________________________________________ Signature of Designee: _____________________________________ Date: ________________________ Subscribed and sworn to before me on this date: ________________________________ Signature of Notary Public: _______________________________________________________________ City of ____________________________________County of __________________________________ State of ______________________________________________ Country: ______________________________________________ My Commission expires: _____________________________________________ Seal: Mail the original Certification and copies of all supporting documents to: Tobacco Enforcement Unit Office of the Attorney General of Vermont 109 State Street Montpelier, Vermont 05609-1001 tobacco@atg.state.vt.us Revised February 15, 2011 5 American LegalNet, Inc. www.FormsWorkFlow.com