Tobacco Manufacturer Certificate {TMC-1}

Indiana Department of Revenue FORM TMC-1 SF#51483 1/04 Part 1: Tobacco Product Manufacturer Identification Company Name Address City State Zip Code Country Email Tobacco Manufacturer Certificate Federal FEIN or SSN TID (if applicable) Telephone Number Name and Title of Person Completing Report Fax Number 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 Non-participating Manufacturer in full compliance with IC 24-3-3 and IC 24-3-5.4-13. Part 2: Sales Year Year of Sales for this Certificate of Compliance is: (complete a separate certification for each year of sales) __________________ Part 3: Brand Family Identification (Attach additional Sheets if Necessary) Participating Manufacturers complete A & B; Non Participating Manufacturers complete A through E. A. Brand Family1 B. Brand Name1 C. Units Sold Sales Year D. Units Sold in Current Year E. Manufacturer Name & Address (if different from above) Part 4: Non-Participating Manufacturer Certification A. Registered Agent for service of process2 Company Agent Name Address City Telephone Number Fax Number State Zip Code Email 1 American LegalNet, Inc. www.FormsWorkflow.com Have you attached proof of appointment (Certificate of Authority) of a Registered Agent? Yes Have you registered with the Secretary of State? Yes No If yes, attach proof of registration. No B. Qualified Escrow Fund - Financial Institution Name of Institution Address City Representative Name State Telephone Number Zip Code Taxpayer Identificaton Number (TID) Escrow Account Number Total amount placed in escrow in the sales year. Total amount held in escrow for the State of Indiana Has the Qualified Escrow Agreement been approved by the Attorney General? Approval Date C. Escrow Deposit/Withdrawal History for Indiana Date Deposit Withdrawal or Transfer3 Balance Part 5: Execution by Authorized Designee Under penalties of perjury, I declare that I have examined this Certification, and to the best of my knowledge and belief, it is true, correct, and complete. Designee (Print Name): Signature of Designee: Title: Date: Subscribed and sworn to before me on this _____________ day of ________________ , _______________ Year My Commission Expires Notary Public Office of Indiana Attorney General ATTN: Tobacco Litigation Section IGC South 5th Floor 302 W. Washington St. Indianapolis, IN 46204 County Indiana Department of Revenue P.O. Box 901 Indianapolis, IN 46206-0901 Mail the completed certificate of compliance to: 1 2 Indicate with an asterisk (*) those brand families or brands that will not be sold in the current year. Submit Certificate of Authority for proof of Registered Agent or proof of having registered to do business in Indiana. 3 Withdrawals must comply with IC 24-3-3-13. Verification of compliance must be provided. 2 American LegalNet, Inc. www.FormsWorkflow.com Tobacco Manufacturer Certificate (TMC-1) General Information Who is required to file this certification? Any tobacco product manufacturer that intends to sell cigarettes within the State of Indiana, 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 IC 24-3-3-14. Definitions: (a) "Brand Family" means cigarettes that are: (1) sold under the same trademark; and (2) differentiated from one another by means of modifiers such as menthol, lights, kings, or 100s. The term includes the use of a brand name, trademark, logo, symbol, motto, selling message, recognizable pattern of colors, or other indicia of product identification that is identical or similar to or identifiable with a previously known brand of cigarettes. (b) "Cigarette" has the meaning set forth in IC 24-3-3-5. (c) "Commission" means the Alcohol and Tobacco Commission created by IC 7.1-2-1-1. (d) "Department" means the Department of State Revenue. (e) "Directory" means the listing of all Brand Families of Tobacco Product Manufacturers that have provided current and accurate certifications conforming to the requirements of IC 24-3-5.4. (f) "Distributor" means a person that: (1) purchases cigarettes on which the tax under IC 6-7-1 is not paid; and (2) stores, sells, or otherwise disposes of the cigarettes. (g) "Foreign Non-participating Manufacturer" means a corporation for profit incorporated under a law other than the law of Indiana. IC 23-1-20-11. (h) "Master Settlement Agreement" has the meaning set forth in IC 24-3-3-6. (i) "Non-participating Manufacturer" means a tobacco product manufacturer that is not a Participating Manufacturer of the Master Settlement Agreement. (j) "Participating Manufacturer" has the meaning set forth in Section II(jj) of the Master Settlement Agreement. (k) "Qualified Escrow Fund" has the meaning set forth in IC 24-3-3-7. (l) "Stamping Agent" means a person that may affix a stamp to a package of cigarettes under IC 6-7-1-15. (m) "Tobacco Product Manufacturer" has the meaning set forth in IC 24-3-3-10. (n) "Units Sold" has the meaning set forth in IC 24-3-3-11. When is this Certification due? This Certificate of Compliance must be filed with the Indiana Attorney General and with the Indiana Department of Revenue on or before August 15, 2003, and for years thereafter by April 30th of the year following the sales year. A manufacturer shall file a supplemental certification with the Attorney General not less than thirty (30) days before the manufacturer adds to or otherwise modifies its list of brand families. Specific Instructions Part 1: Manufacturer Identification Identify the name, FEIN or SSN, address, TID (if applicable), telephone, fax number, electronic mail address, and name and title of person completing report. Please check if manufacturer as of the date of certification is a Participating or Non-participating Manufacturer. Part 2: Sales Year The calendar year before the year in which the certification is being filed. 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 Participating Manufacturer shall include a list of its Brand Families and