CERTIFICATION OF ENROLLMENT – STATE OF WASHINGTON [Laws of 2003, Chapter 25] GENERAL INFORMATION Who is required to file this certification? Any tobacco product manufacturer that intends to sell cigarettes within the state of Washington, whether directly or through any distributor, retailer, or similar intermediary. This Certification is in addition to any Certificate of Compliance that may be required pursuant to RCW 70.157. Definitions: (Laws of 2003, ch. 25) (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,” “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. (b) “Board” means the Liquor Control Board. (c) “Cigarette” means any product that contains nicotine, is intended to be burned or heated under ordinary conditions of use, and consists of or contains (1) any roll of tobacco wrapped in paper or in any substance not containing tobacco; or (2) tobacco, in any form, that is functional in the product, which, because of its appearance, the type of tobacco used in the filler, or its packaging and labeling, is likely to be offered to, or purchased by, consumers as a cigarette; or (3) any roll of tobacco wrapped in any substance containing tobacco which, because of its appearance, the type of tobacco used in the filler, or its packaging and labeling, is likely to be offered to, or purchased by, consumers as a cigarette described in clause (1) of this definition. The term “cigarette” includes “roll-your-own” (i.e., any tobacco which, because of its appearance, type, packaging, or labeling is suitable for use and likely to be offered to, or purchased by, consumers as tobacco for making cigarettes). For purposes of this definition of “cigarette,” 0.09 ounces of “roll-your-own” tobacco shall constitute one individual “cigarette.” (d) “Director” means the Director of the Department of Revenue except as otherwise noted. (e) “Directory” means the listing of all Tobacco Product Manufacturers that have provided current and accurate certifications conforming to the requirements of Laws of 2003, ch. 25, and all Brand Families that are listed in such certifications; except as provided by Laws of 2003, ch. 25. (f) “Distributor” means (a) any person engaged in the business of selling tobacco products in this state who brings, or causes to be brought, into this state from without the state any tobacco products for sale, (b) any person who makes, manufactures, or fabricates tobacco products in this state for sale in this state, (c) any person engaged in the business of selling tobacco products without this state who ships or transports tobacco products to retailers in this state, to be sold by those retailers, except that for purposes of this chapter, no person is a distributor if that person does not deal with cigarettes as defined in this section. (g) “Master Settlement Agreement” means the settlement agreement (and related documents) entered into on November 23, 1998 by the State and leading United States tobacco product manufacturers. (h) “Non-participating Manufacturer” 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. -1- American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION OF ENROLLMENT – STATE OF WASHINGTON [Laws of 2003, Chapter 25] (j) “Qualified Escrow Fund” means an escrow arrangement with a federally or State chartered financial institution having no affiliation with any tobacco product manufacturer and having assets of at least $1,000,000,000 where such arrangement requires that such financial institution hold the escrowed funds’ principal for the benefit of releasing parties and prohibits the tobacco product manufacturer placing the funds into escrow from using, accessing or directing the use of the funds’ principal except as consistent with RCW 70.157.020(b). (k) “Stamp” means the stamp or stamps by use of which the tax levy under this chapter is paid or identification is made of those cigarettes with respect to which no tax is imposed, or as referred to in RCW 43.06.455(4). (l) “Tobacco Product Manufacturer” or “manufacturer” has the same meaning as in RCW 70.157.010(i). (m) “Units Sold” means the number of individual cigarettes sold in the State by the applicable tobacco product manufacturer (whether directly or through a distributor, retailer or similar intermediary or intermediaries) during the year in question, as measured by excise taxes collected by the State on packs bearing the excise tax stamp of the State or “roll-your-own” tobacco containers. The Department of Revenue shall promulgate such regulations as are necessary to ascertain the amount of State excise tax paid on the cigarettes of such tobacco product manufacturer for each year. (n) “Wholesaler” means every person who purchases, sells, or distributes any one or more of the articles taxed herein to retailers for the purpose of resale only. When is this certification due? This certificate of compliance must be filed with the Attorney General on or before April 30th of the year following the sales year. SPECIFIC INSTRUCTIONS Part 1: Manufacturer's Identification. Identify the manufacturer’s name, address, telephone, fax number, email address, name a contact person, and list the website address. Give the manufacturer’s physical delivery or street address if different from the mailing address. Part 2: Sales Year. Identify the sales year. Part 3: Brand Family Identification. Identify by Brand Family and Brand Names all of the cigarettes that the Tobacco Product Manufacturer 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-B Participating Manufacturer shall include a list of its Brand Families and Brand Names. The Participating Manufacturer shall update such 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. Lists of more than 10 brand styles should be submitted electronically as an attachment to an email directed to twyla.williams@atg.wa.gov. Email attachments must be less than 30 MB in size. If the electronic file is larger than 30 MB, the brand styles list must be submitted on CD with the original form. The signed original of this form must be transmitted by U.S. Mail or courier. A-E 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) a list of all of its Brand Families that have been sold -2- American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION OF ENROLLMENT – STATE OF WASHINGTON [Laws of 2003, Chapter 25] in the State at any time during the current calendar year, (iii) indicating, by an asterisk, any Brand Family 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, 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 calendar days prior to any addition to or modification of its Brand Families and Brand Names by executing and delivering a supplemental certification to the Attorney General. Lists of more than 10 brand styles should be submitted electronically as an attachment to an email directed to twyla.williams@atg.wa.gov. Email attachments must be less than 30 MB in size. If the electronic file is larger than 30 MB, the brand styles list must be submitted on CD with the original form. The original of this form must be transmitted by U.S. Mail or courier. F. To be completed by all Tobacco Product Manufacturers. Attach a copy of the NonParticipating Manufacturer’s registration with the U.S. Department of Justice under the Jenkins Act as amended by PACT (Title 15 U.S. Code). Registration requires completion of ATF Form 5070.1 which can be found at http://www.atf.gov/forms/alcohol-tobacco/. Attach verification of transmittal of a copy of ATF Form 5070.1 to the Washington Department of Revenue, Excise Tax Examiner, P.O. Box 47477, Olympia, WA 98504. G. To be completed by all Tobacco Product Manufacturers. Attach a copy of the certification from the Washington State Fire Marshal showing that all brand styles to be certified for sale in Washington are “fire safe” as defined in RCW 19.305 Cigarette Ignition Propensity. More information concerning Fire Safe Certification can be found at http://www.wsp.wa.gov/fire/firesafe_cigarettes.htm. Part 4: Non-Participating Manufacturer Certification. A. Attach a copy of the current, effective permit to manufacture tobacco products issued by the U.S. Treasury, Tobacco Tax Bureau (TTB). If the permit has been amended, attach copies of all amendments. B. Verify either: (1) that the Non-Participating Manufacturer is not registered to do business in the State of Washington but has appointed an agent for service of process as designated in the Attorney General Statement of Registered Agent form and provided notice thereof; or (2) that the NonParticipating Manufacturer is registered to do business in the State of Washington and has appointed an agent for service of process and provided notice thereof as required by RCW 23B.15. C. List all other states in which the Non-Participating Manufacturer is certified to sell tobacco products to date for the current sales year. Attach additional sheets if necessary. D. Identify the Washington-licensed distributors or wholesalers to which cigarettes were or will be sold and provide company name, contact person name, address, phone and email for each such entity. E. (1) If the NPM Applicant has been enjoined or banned from selling tobacco products by any court order or government agency ruling or determination, list the courts or government agencies issuing any such orders. (2) If the NPM Applicant has had a judgment entered against it for failure to pay any escrow funds alleged to be due, list the courts issuing any such judgments and give the identifying case caption and assigned case number for each such action. -3- American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION OF ENROLLMENT – STATE OF WASHINGTON [Laws of 2003, Chapter 25] F. Identify the source of the tobacco used in fabricating the cigarettes to be offered for sale in Washington? List the company name, address, phone and email for each provider of tobacco used. G. Attach a copy of the federal approval documentation obtained from (1) the Department of Health & Human Services, Centers for Disease Control for the ingredient listing showing the expiration date of the approval; and (2) the health warning label rotation plan obtained from the FTC (or its successors) showing the expiration date of the approval. Additional information is available (1) for the Centers for Disease Control at http://www.cdc.gov/tobacco/basic_information/tobacco_industry/reporting/instructions/ and (2) for the Federal Trade Commission at http://www.ftc.gov/bcp/policystmt/cigarettememo.shtm. H. Attach a copy of ownership documentation for any trademarks registered with the U.S. Patent & Trademark Office for all brand families to be offered for sale in Washington. If any assignments or other agreements exist concerning the use of the trademark for the purpose of marketing cigarettes in the U.S., attach copies of those documents. Additional information is available at http://www.uspto.gov/. I. Identify (i) the name, address, and telephone number of the financial institution where the Non-Participating Manufacturer has established a Qualified Escrow Fund pursuant to RCW 70.157.020(b)(1); and (ii) the account number of such Qualified Escrow Fund and any subaccount number for the state. The Escrow Agreement must be provided upon initial application. If the current executed Escrow Agreement has previously been approved, it is not necessary to attach another copy of the Escrow Agreement to this form. J. Identify (i) the amount such Non-Participating Manufacturer placed in such Fund for cigarettes sold in the State during the preceding calendar year, and the date and amount of each such deposit; and (ii) 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. Part 5: Execution by Authorized Designee. The person executing the Certification must be an authorized representative 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. Please note that the Washington Attorney General’s Office has the right to request additional information. You will receive a letter requesting additional information if the State so elects. Your application will not be complete until all requests for information are satisfied. -4- American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION OF ENROLLMENT – STATE OF WASHINGTON [Laws of 2003, Chapter 25] PART 1: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION Company: ____________________________________________________________________________________ Address: ____________________________________________________________________________________ Physical/Street address if different: _______________________________________________________________________________ Phone: _______________________________________ FAX _____________________________________ Email: _______________________________________ WEBSITE_________________________________ Name and Title of Person Completing Report: ____________________________________________________________ Person to Contact and Phone/Email (if different):__________________________________________________________ The Tobacco Product Manufacturer identified above is, as of the date of this Certification: (Initial One) ________ A Participating Manufacturer under the Tobacco Master Settlement Agreement ________ A Tobacco Product Manufacturer in full compliance with RCW 70.157 PART 2: SALES YEAR Year of Sales for this Certificate of Enrollment is: ______________ (Complete a separate Certificate of Compliance for each year of sales) PART 3: BRAND FAMILY IDENTIFICATION (Attach additional Sheets if Necessary. Submit list of more than 10 brand styles electronically attached to an email to twyla.williams@atg.wa.gov ) Participating Manufacturers complete A, B, F, and G; Non Participating Manufacturers complete A through G. A. Brand Family1 B. Brand Name C. Units Sold Preceding Yr D. Units Sold Current Yr E. Manufacturer F. Have you attached a copy of your federal PACT Registration as filed with U.S. Department of Justice?________ 1 Indicate with an asterisk (*) those brands that will not be sold in 2011. -5- American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION OF ENROLLMENT – STATE OF WASHINGTON [Laws of 2003, Chapter 25] G. Have you attached a copy of the current fire safe certification from the Washington State Fire Marshal for all brand styles listed above? _________ PART 4: NON-PARTICIPATING MANUFACTURER CERTIFICATION A. Have you attached a copy of the current U.S. Treasury, Tobacco Tax Bureau (TTB) permit(s) as a manufacturer? _________________________________________________________________________________ If the NPM Applicant has previously provided its TTB permit and that permit continues to be current, in effect, and operative, check here _____. If checked, no additional copy of the permit is required. B. Registered Agent for service of process2 Agent Name: ____________________________________________________________________________________ Company: ____________________________________________________________________________________ Address: ____________________________________________________________________________________ ____________________________________________________________________________________ Phone: _________________FAX _________________Email: _______________________________________ (1) Have you attached proof of appointment (Certificate of Authority) of a Registered Agent? See RCW 23B.15: _______ (2) is the NPM Applicant registered to do business in the State of Washington?________ C. List all other states in which you are certified in 2011______________________________________________ __________________________________________________________________________________________________ D. Identify the Washington-licensed Distributors or Wholesalers to which cigarettes were or will be sold and provide contact person, address, phone, and email for each entity: (1) (2) (3)______________________________________________________________________________________________ E. (1) Has the NPM Applicant been enjoined or banned from selling tobacco products by any court order or government agency ruling or determination? _______ (2) Has the NPM Applicant had a judgment entered against it for failure to pay any escrow funds alleged to be due?_______ If you answered yes to either (1) or (2), list the courts or government agencies issuing any such orders or judgments and give the identifying case caption and assigned case number: ________________________________________________________________________________________________ F. What is the source of the tobacco used in fabricating the cigarettes identified above? List the provider, address, phone, and email: ________________________________________________________________________________________________ ________________________________________________________________________________________________ G. Have you attached federal approval documentation? ____________________________________________ (1) Current HHS/CDC approved ingredient listing dated ______________________________________________ (2) FDA or FTC Health warning label rotation plan dated _____________________________________________ H. Have you attached ownership documentation of any trademarks registered with the U.S. Patent & Trademark Office for all brand families listed above? __________________________________________________ If the applicant has previously provided Trademark ownership documentation and that ownership has not been assigned, transferred or amended, check here _____. 2 Submit Certificate of Authority for proof of Registered Agent. -6- American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION OF ENROLLMENT – STATE OF WASHINGTON [Laws of 2003, Chapter 25] If checked, no additional copy of the Trademark documentation is required. I. Qualified Escrow Fund – Financial Institution Name of Institution: ______________________________________________________________________________ Address: ______________________________________________________________________________ Representative Name: ________________________________________ Phone:_______________________________ Escrow Acct No: ________________________________________ State Account No: _____________________ Have you attached the current Escrow Agreement and any amendments or attachments to it? ________________ If the NPM Applicant has previously provided the effective Escrow Agreement, check here __________. If checked, no additional copy of the Escrow Agreement is required. J. Escrow Deposit/Withdrawal History for Washington Date Deposit Withdrawal3 Balance Part 5: Execution by Authorized Designee Under penalty of perjury, I state that the information contained in this Certification is true and accurate. Designee (Print Name): ________________________________________ Title: _______________________ Signature of Designee: Date: _______________________ ________________________________________ Subscribed and sworn to before me on this date: ________________________________________________________ Signature of Notary Public: _____________________________________ City or County of_____________________ My Commission expires: ________________________________________ Mail the completed certificate of compliance to the following mailing address or if by courier, to our geographical address: NPM Coordinator OR NPM Coordinator Office of the Attorney General Office of the Attorney General Revenue Division Revenue Division PO Box 40123 7141 Cleanwater Drive SW Olympia, WA 98504-0123 Tumwater, WA 98501 3 Withdrawals must comply with RCW 70.157. Verification of compliance must be provided. -7- American LegalNet, Inc. www.FormsWorkFlow.com