Consent To Suit

STATE OF TENNESSEE · CONSENT TO SUIT Pursuant to TENN. CODE ANN. § 67-4-2602 CERTIFICATION YEAR 2016 BUSINESS INFORMATION: Business Name: Address: State: Telephone: CONSENT TO SUIT: The above-named Non-Participating Manufacturer does hereby consent that any action or proceeding against it, pursuant to TENN. CODE ANN. §§ 47-31-101 et seq ., and pursuant to TENN. CODE ANN. §§ 67-4-2601 et seq ., by the State of Tennessee, may be commenced in any state court of competent jurisdiction within Tennessee. Contact Person: City: Zip Code: Email: INITIAL: REQUIRED DOCUMENTATION: Attached: Proof of authority to consent to suit on behalf of the Non-Participating Manufacturer, e.g .,a resolution by the NonParticipating Manufacturer specifically agreeing to consent to suit provision, as well as any required approval by an applicable governmental agency, whether federal, state, county, local, or tribal. Proof of authority given to the signing party to execute the consent to suit provision. Attached: SIGNATURE: Authorized Designee: Designee Signature: BUSINESS INFORMATION: Subscribed and Sworn Before Me on this Date: Signature of Notary Public City or County of: My Commission Expires: MAIL THE COMPLETED CERTIFICATION FORM TO: Office of the Attorney General Revenue Section Tobacco Enforcement Division P.O. Box 20207 Nashville, TN 37202-0207 This form, including attachments, must be returned to the address shown on the left. This form will be returned and left unprocessed unless all fields are completed and all required attachments received. Title: Date: State of: American LegalNet, Inc. www.FormsWorkFlow.com updated 01/2016