Wisconsin Department of Justice PO Box 7857 Madison WI 53707-7857 Phone: (608) 266-0180 Department Use Only State of Wisconsin Registration No. Certification by Non-Participating Manufacturer I. MANUFACTURER IDENTIFICATION New (refer to CTP-124) Renewal (refer to CTP-124) (Please print or type) Legal Name Certification for Sales Year Trade or Business Name Address Mailing Address (if different from above) Phone ( Fax ) E-mail Phone ) Contact Person Name A. Website Title ( Domestic Manufacturer (fabricator) (Located in the U.S.) Federal Employer Identification No. (FEIN) WDOR Permit No. CMFR - B. TMFR - Foreign Manufacturer (fabricator) II. BUSINESS OPERATIONS Complete all areas. If not applicable, enter “N/A”. A. U.S. Manufacturer (fabricator) » U.S. Federal Manufacturer Permit: TP5210.5 federal reporting forms for prior year » Products Manufactured (check all that apply) Cigarettes See attached permit labeled “Exhibit See attached reports labeled “Exhibit Roll-Your-Own (RYO/MYO) Little Cigars As Bulk Loose Tobacco As Prepackaged Tobacco ”. ”. B. U.S. Importer » U.S. Federal Importer Permit: Products Imported (check all that apply) Cigarettes TI See attached permit labeled “Exhibit Roll-Your-Own (RYO/MYO) Little Cigars As Bulk Loose Tobacco As Prepackaged Tobacco ”. C. U.S. Exporter » U.S. Federal Exporter Permit: Products Exported (check all that apply) Cigarettes See attached permit labeled “Exhibit Roll-Your-Own (RYO/MYO) Little Cigars As Bulk Loose Tobacco As Prepackaged Tobacco ”. D. Manufacturer (fabricator) Outside the U.S. » Products Manufactured (check all that apply) See attached government and/or local license(s)/permit(s) labeled “Exhibit Cigarettes Roll-Your-Own (RYO/MYO) Little Cigars As Bulk Loose Tobacco As Prepackaged Tobacco ”. E. Exporter to U.S. » EW- - Government and/or Local License(s)/Permit(s)? Products Exported to U.S. (check all that apply) Cigarettes Do you export any tobacco products fabricated by another person? Yes, see attached permit labeled “Exhibit No, see explanation labeled “ Exhibit Roll-Your-Own (RYO/MYO) As Bulk Loose Tobacco As Prepackaged Tobacco ”. ”. Little Cigars ” Yes » See attached detailed list labeled “Exhibit of products by brand and manufacturer (fabricator). No CTP-121 (R. 3-07) Wisconsin Department of Revenue American LegalNet, Inc. www.FormsWorkflow.com III. MANUFACTURER BUSINESS ORGANIZATION Legal Name Certification for Sales Year A. Organization (check one) Sole Proprietor Partnership Wisconsin Corporation – Enter date incorporated: Out-of-State / Country Corporation – Are you registered to do business in Wisconsin? YES NO If Governmental Unit, check appropriate box Federal County State/Provincial Agency Local Limited Liability Company – Enter date registered with the Secretary of State or equivalent: Other – Describe: For federal income tax purposes, will the LLC be taxed as a: Partnership Corporation Tribal Single member LLC disregarded as a separate entity • List all states in which you are registered with the Secretary of State or equivalent • Indicate the state/province/country where your business was formed and attach copies of current articles [or similar such document(s)] and bylaws labeled as Exhibit . B. For the organization marked in “A” above, complete the following for each individual, partner, or member and each officer, director, agent and holder of 5% or more stock. If additional space is needed, attach additional sheet(s) in the same format as below. (MUST BE COMPLETED.) Name SS# / Date of Birth Home Address & Phone Number (including international & area code) City / Town / Village State Country Zip Code Position / Title Percent of Stock Held Identify by ( * ) any person in B. above who: a) has an ownership interest or holds a management position in your firm; and (b) within the past five years has had an affiliation with, been employed or otherwise compensated by, a tobacco product manufacturer, distributor, importer or other such business involved with the sale or purchase of tobacco products. For each person that has such a relationship, identify the particular tobacco company with which the person is associated. Attach this list labeled as “Exhibit ”. C. Enter the name(s) and dates below under which you have conducted business in the past five (5) years involved with the sale or purchase of tobacco products. If additional space is needed, attach additional sheet(s) in the same format as below. Legal Name Doing Business As (DBA) Date of Change I certify, under penalty of perjury, that all of the information contained in this Certification Form (CTP-120 / CTP-121) and all related schedules (CTP-122, CTP-122a, CTP-122b, CTP-122c and CTP-123, CTP-123a, CTP-123b, CTP-123c and CTP-124 or CTP-126) and all supporting documentation is true, accurate, and complete. I further certify that the above named Manufacturer is in full compliance with Wisconsin Statutes ss. 995.10, 995.12, and Wisconsin Chapter 139 and all related Codes and all rules adopted pursuant to those chapters. The signature on this Certification Form must be notarized by an authorized notary public. Name of Owner, Officer, Partner or Director of Manufacturer and title (please print or type) Signature of Owner, Officer, Partner or Director of Manufacturer Signature of Notary Public Date Subscribed and sworn to before me on this date (seal) City or County of My Commission Expires on Mail this Certification Form to the Attorney General: Any change or modification should also be mailed to: Tobacco Enforcement Coordinator Wisconsin Department of Justice PO Box 7857 Madison WI 53707-7857 Wisconsin Department of Revenue Excise Mail Stop 5-107 PO Box 8900 Madison WI 53708-8900 2 American LegalNet, Inc. www.FormsWorkflow.com