Non-Participating Manufacturers Request For Units Sold Information

STATE OF TENNESSEE Office of the Attorney General and Reporter Revenue Section Tobacco Enforcement Division Post Office Box 20207 Nashville, TN 37202-0207 NON-PARTICIPATING MANUFACTURER'S REQUEST FOR "UNITS SOLD" INFORMATION I. Company Information Sales Year: _________ ___ ______ Non-Participating Manufacturer: Address: Telephone: E-mail: Authorized Representative Making Request: II. Request for "Units Sold" Information On behalf of the above-identified Non-Participating Manufacturer, _________________ ______________________________________, hereby requests that the Tennessee Office of the (Authorized Representative) 1 Attorney General's Tobacco Enforcement Division (hereinafter the "State") disclose the number of "Units Sold", defined at Tenn. Code Ann. § 47-31-102(10), for the following brand families: ________________________________________________________________, sold to licensed 1 (NPM Brand Families) Tennessee tobacco wholesalers during the following time period: ________________________. 1 (Year/Quarter) By executing this request form, I acknowledge that Tennessee has the authority to revise its calculation of the number of Units Sold if any new or amended information is received at any time. I further acknowledge that the above-identified Non-Participating Manufacturer is required to track its sales to licensed Tennessee tobacco wholesalers in accordance with Tenn. Code Ann. § 47-31-102(10) and § 47-31-103. Facsimile: Revised January 2016 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com III. Manufacturer Brand Totals of Units Sold During ____________________________ (Year/Quarter) ** These totals are for sales to all licensed Tennessee tobacco wholesalers, whether those licensed Tennessee tobacco wholesalers are located within the State or whether they are located out of state. (Please fill out a separate line for each brand family sold by a wholesaler) Number of Ounces of RYO Sold Wholesaler Name and Address Brand Family Sold Number of Units Sold Total Number of Units Sold to all Tennessee Wholesalers for____________ is ___________. (Quarter/Year) (Total Number) Total Number of Ounces of RYO to all Tennessee Wholesalers for ________ is __________. (Quarter/Year) (Total Number) Revised January 2016 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com IV. Confidentiality Agreement On behalf of the above-identified Non-Participating Manufacturer, I, ________________ __________________________________________, hereby agree not to disclose the Units Sold (Authorized Representative) information provided by the State in response to this request, including wholesaler data collected by the Tennessee Department of Revenue, to anyone other than employees and representatives of the above-named Non-Participating Manufacturer. V. Signature __________________________________ Authorized Representative ___________________________________ Date Revised January 2016 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com