Participating Tobacco Product Manufacturer Certificate Of Compliance

Page 1 of 4) STATE OF OHIO PARTICIPATING TOBACCO PRODUCT MANUFACTURER CERTIFICATE OF COMPLIANCE Pursuant to R.C. 1346.02 and 1346.05 and Ohio Adm.Code 109:8-1-01 thru 109:8-1-03 PART 1: PARTICIPATING TOBACCO PRODUCT MANUFACTURER IDENTIFICATION A.CompleCompany Name TTB Permit Number Address P.O. Box City/State/Zip/Country Telephone Number: Fax Number E-Mail Address Website URL Name/Title of Person Completing Form B.This form is (check one below): Annual Certification Due A April 30, 201 for Ohio sales in 201 Initial CeManufacturer is not currently listed on the Ohio Tobacco Directory Supplemental Certification Change of information provided to the Attorney General PART 2: PARTICIPATING MANUFACTURER BRAND FAMILY IDENTIFICATION A.List the brands which are beOhio Tobacco Directory. Brand Name Cigarette RYO Brand Name Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO B.List any new brands that are not currently listed on the Ohio Tobacco Directory which the manufacturer identified in Part 1A intends to sell in Ohio. Bra Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO C.Identify any brands currently listed on the Ohio Tobacco Directory that are no longer being sold bythe manufacturer identified inBrand Name Cigarette RYO Brand Name Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Click to Expand Tables Page 2 of 4 Form PM001 (Rev. 0/201) PART 3: REQUIRED ATTACHMENTS For each brand certified in Parts 2A and 2B of this Certificate of Compliance, complete a BrandIdentification Form PM002 (Rev. 03/201) . A copy of the current U.S. Treasury Tobacco Tax Bureau (TTB) permit as a manufacturer and/or importer asrequired by 26 U.S.C. §5712 and §5713 must be provided for the tobacco product manufactureridentified in Part 1A of this form. To ensure compliance with Ohio Adm.Code 109:8-1-02(A)(5), provide a Statement of Condition from theOhio Department of Taxation. Please contact the Ohio Department of Taxation at: D. If not previously submitted, or if changed since last submission, provide original packaging for o one brand style which is representative of each brand family certified in Parts 2A and 2B of this form. Flat empty cartons and packs are preferred. Submit new packaging each time you change your packaging or add newbrand families. C Check one below: Packaging for each brand family has not been previously submitted/has changed. Samples are enclosed. Packaging for each brand family has been previously submitted and has not changed PART 4: ADDITIONAL INFORMATION A. Pursuant to R.C. 3739.07, a manufacturer must submit to the State of Ohio Fire Marshal a certificationthat its brands meet the requirements of the Reduced Ignition Propensity Standards for Cigarettes. P Pleasecheck below: Each brand family listed in Part 2A and 2B meets the requirements of the Reduced Ignition Propensity Standards for Cigarettes in Ohio. A certification must be submitted with this Certificate of Compliance. B. Pursuant to the federal Prevent All Cigarette Trafficking (?PACT?) Act, 15 U.S.C. §§375, et.seq., all personswho sell, transfer, or ship cigarettes (including roll-your-own tobacco) in interstate commerce for profit, orwho offers cigarettes for such a sale, transfer, or shipment must: (1) register with the tobacco taxadministrator of the state into which shipment is made; and (2) file monthly reports with the tobacco taxadministrator (Ohio Department of Taxation), no later than the 10th of each month, identifying the brands,quantities, and recipients of cigarette shipments into such state. P Please check below: The Tobacco Product Manufacturer listed in Part 1A is in full compliance with the PACT Act, including but not limited to: registering and filing monthly reports with the Ohio Department of Taxation. C. Pursuant to R.C. 2927.023 the shipment of cigarettes to anyone in Ohio other than ?authorized recipients?of tobacco products, as that term is defined in R.C. 2927.023(A)(1), is strictly prohibited. Ohio lawrequires that all direct cigarette sales to Ohio consumers be made in a ?face?toface? transaction. Thus,cigarettes cannot be sold via the Internet to Ohio consumers. P Please check below: The Tobacco Product Manufacturer listen Part 1A is in full compliance of R.C. 2927.023. Attach TTB Permit Click Here to Request a Statement of Condition *Please note - the link takes you to the Ohio Department of Taxation website - the request must be submitted, per instructions, to the Ohio Department of Taxation. Attach Statement of Condition Attach R.I.P.C Certification Page 3 of 4 PART 5: PARTICIPATING MANUFACTURER IMPORTER 1.Is the participating manufacturer located outside of the United States? Yes No 2.If your answer is ?Y Yes ?, please identify the name and address of the importer: Importer Name: Importer Address: Importer Contact Name: Importer Phone Number: Page 4 of 4 PART 6: AFFIDAVIT OF TOBACCO PRODUCT MANUFACTURER This certification M MUST be signed by a qualified company officer of the manufacturer i identified in Part 1A to bind the applicant company. This form M MUST be notarized. My position with the company and my actual authority to certify on behalf of the applicant meets the foregoing requirements: I understand that the Attorney General may require additional information or documentation to determine if applicant or brands qualify for listing on the Ohio Directory. I have examined this Certification, including attachments and supporting documents and, to the best of my knowledge and belief, this Certification, including attachments and supporting documents, is true, correct, and complete. I understand that in the event the information submitted is no longer accurate, the manufacturer shall notify the Attorney General. On behalf of the Applicant the undersigned agrees that any action or proceeding against it arising from enforcement of the provisions of R.C. 1346.01 through 1346.10 and any rules promulgated pursuant to these statutes, may be commenced against Applicant in any state court within Ohio, that the laws of the State of Ohio will govern such proceedings, and that Applicant waives any immunity from suit, liability, judgment and collection that Applicant may possess. Under penalty of falsification, I state that the tobacco product manufacturer named in Part 1A, as of the date of this certification, is a participating manufacturer in full compliance with all applicable sections of Chapter 1346 of the Ohio Revised Code, any rules adopted under those sections, and with the MSA amendment and or agreement applicable to its admission into the MSA. By signing this affidavit on behalf of the applicant company I understand that the company is required to comply with state and federal laws concerning the sale of tobacco products. Name of Owner/ Officer of Participating Tobacco Product Manufacturer (print name) Title Signature of Owner/Officer DateSubscribed and sworn to this date: State/County of: Signature of Notary Public: Notary Commission expires: Print This Page Mail fully executed Affidavit of Tobacco Product Manufacturer to: Ohio Attorney General's Office Tobacco Enforcement Unit 30 East Broad Street, 26th Floor Columbus, Ohio 43215Form PM002 (Rev. 0/201) PARTICIPATING TOBACCO PRODUCT MANUFACTURER BRAND IDENTIFICATION FORM (Copy this form and attach for each additional brand) Pursuant to R.C. 1346.02 and 1346.05 and Ohio Adm.Code 109:8-1-01 thru 109:8-1-03 The participating manufacturer identified in Part 1 of the Certificate of Compliance has the following brand, which the tobacco product manufacturer affirms is deemed its cigarette or RYO tobacco for purposes of R.C. 1346.02 and 1346.05. Please note that pursuant to R.C. 1346.05(A)(4)(b) the Attorney General retains the discretion to determine that the cigarettes or RYO tobacco in a brand family constitute the cigarettes of another tobacco product manufacturer. Complete for each brand sold in the 201 calendar year and at any time in the current calendar year. 1.Participating Manufacturer Name: 2.Brand Identification and Sales Information 2a. Brand Name: 2b. Cigaret