Certification Of Tobacco Product Manufacturer That Signed Master Settlement Agreement Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Certification Of Tobacco Product Manufacturer That Signed Master Settlement Agreement Form. This is a West Virginia form and can be use in Office Of The Attorney General Statewide.
Loading PDF...
Tags: Certification Of Tobacco Product Manufacturer That Signed Master Settlement Agreement, West Virginia Statewide, Office Of The Attorney General
State of West Virginia
Certification of Tobacco Product Manufacturer That
Signed Master Settlement Agreement
(Pursuant to WV Code ยง 16-9D-3)
Part 1: Tobacco Product Manufacturer Identification
Tobacco Company Manufacturer Information
Company Name:
Street Address:
City:
State/Country:
Postal Code:
Telephone:
Fax:
Email:
Name/Title of Person
Completing Report:
Page 1 of 3
American LegalNet, Inc.
www.FormsWorkFlow.com
Part 2: Brand Family Identification (attach additional sheets if
necessary)
The Participating Manufacturer identified in Part 1 has the following Brand Families,
each of which the manufacturer hereby affirms are to be deemed its Cigarettes for
purposes of calculating its payments under the Master Settlement Agreement for the
relevant year, in the volume and shares determined pursuant to the Master Settlement
Agreement.
Brand Families (List Below)
Page 2 of 3
American LegalNet, Inc.
www.FormsWorkFlow.com
Part 3: 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:
Mailing Address:
Telephone:
Email:
Signature of Designee:
Date:
Subscribed and sworn
to before me on this
date:
City or County of
My Commission
expires:
Signature of Notary
Public:
Mail the completed certificate of compliance to:
Tobacco Litigation Unit
The Office of the Attorney
State Capitol Complex
Building 1, Room W-435
Charleston, WV 25305
and
West Virginia State Tax Department
General Excise Tax Unit
P.O. Box 2991
Charleston, WV 25330-2991
Page 3 of 3
American LegalNet, Inc.
www.FormsWorkFlow.com