Ga. Comp. R. & Regs. 60-1-1-.15
CERTIFICATION PURSUANT TO O.C.G.A. § 10-13A-3
STATE OF GEORGIA
Part 1: Tobacco Product Manufacturer Identification
Company: ____________________________________________________ Address: ________________________________________________________ Address: ________________________________________________________ Phone: ______________________________
FAX: _______________________________
Email: ________________
Web Address:____________
Name/Title of person completing report:____________
If located in the U.S.: Manufacturer's Federal I.D #:____________
If located in the U.S.: TTB Tobacco Manufacturer Permit #:____________
The Tobacco Product Manufacturer identified above is, as of the date of this Certification: (check one)
________A Participating Manufacturer under the Tobacco Master Settlement Agreement
________A Non-Participating Tobacco Product Manufacturer in full compliance with O.C.G.A. § 10-13-1, et seq.
Part 2: Certification Type
This form is a (check one):
_____________Initial Certification: manufacturer is not currently listed on the Georgia Directory of Compliant Tobacco Product Manufacturers
__________ Annual Certification:
__________Supplemental Certification: change of information previously provided - change must be submitted 30 days prior to change.
Part 3:
A. Brand Family Identification (Attach additional Sheets if Necessary)
Participating Manufacturers complete A & B;
Non-Participating Manufacturers complete A through E.
A. Brand Family[1] | B. Brand Name | C. Units Sold in calendar year just completed | D. Units Sold in previous year | E. Fabricator |
Note: By including a brand family in its certification, a Participating Manufacturer affirms that the brand family is deemed to be its cigarettes for purposes of calculating its payments under the MSA. By including a brand family in its certification, a Non-Participating Manufacturer affirms that the brand family is deemed to be its cigarettes for escrow purposes. However, the Attorney General retains the discretion to determine whether the listed brand family constitutes the cigarettes of another tobacco product manufacturer.
It is unlawful to offer for sale in Georgia any cigarette that is not compliant with the Georgia Fire Safety Standards & Firefighter Protection Act, O.C.G.A. § 24-4-1, et seq. ("fire safe" cigarette act)
Do not list a brand family unless the required information has been submitted to the Georgia Fire Safety Commissioner and required package markings approved.
B. For each brand family listed above, list the name and address of any other manufacturer who has fabricated or is currently fabricating the brand family: ____________________
________________________________________________________________
________________________________________________________________
C. Factory Identification
Name of Factory: _______________ Phone Number: _________________
Owner of Factory: ______________________ Fax Number: ____________
Address of Factory: ______________________________________________
Factory's Manufacturing Permit Number: _________________________
Part 4: Non-Participating Manufacturer Certification
A. Registered Agent/Approved Agent for service of process
Agent Name: __________________________________________
Company: _________________________________________________
Address, including county: _________________________________
Address: __________________________ ___________________
Phone: _____________________ FAX: ____________________
Email: _________________________________________
Complete and submit an Appointment of Registered Agent for the State of Georgia and Registered Agent's Statement form. (Form AG-02)
B. Qualified Escrow Fund - Financial Institution
Name of Institution: _____________________________________
Address: _________________________________________
Representative Name: ________________________________________ Phone: _______________________________
Escrow Acct No: ______________ State Account No: ________________
Has the Qualified Escrow Agreement been approved by the Attorney General? _________
By Whom: ____________________ Approval Date: __________
Attach an executed copy of your Escrow Agreement with all amendments and attachments.
Part 5: Escrow Deposit Calculation
A. Sales Year: The sales year for this certificate is January 1 through December 31, ____
B. Units Sold: The number of individual cigarettes sold in Georgia by brand is:
Brand Name: ___________________ Number of individual cigarettes: ________
Brand Name: ___________________ Number of individual cigarettes: ____________
Brand Name: ___________________ Number of individual cigarettes: ____________
Brand Name: ___________________ Number of individual cigarettes: ____________
Total: ___________
C. Calculating the Deposit Amount
Follow these steps to calculate the appropriate amount to be deposited for the sales year:
(1) Enter the total number from Part 5 Section B above: _______
(2) Multiply that amount by the appropriate rate for the liability year as set forth in Rule 60-1-1-.09: ________
(3) Enter the total here: ________
The amount that must be deposited on or before April 15 for the sales year will be the amount shown in Line C(3).
D. Escrow Deposit/Withdrawal History for Georgia
Date | Deposit | Withdrawal[2] | Balance |
Attach a copy of your receipt or other proof of deposit from your financial institution.
E. Describe the source of funds for previous year's escrow payments and anticipated source of funds for future escrow payments: ________________________________________________________________
________________________________________________________________
Part 6. Execution by Authorized Designee
This certification must be signed by a qualified company officer authorized to bind the applicant company.
By executing this document, I confirm that my position with the company and my actual authority to certify on behalf of the applicant meets the foregoing requirements. I understand the Georgia Attorney General may require additional information or documentation to determine if the applicant company or brands qualify for the Georgia Directory.
Under penalty of perjury, I state that the information contained in this Certification and attachments is true and accurate.
Designee (Print Name): ____________________ Title: _______________
Signature of Designee: _____________________ Date: _______________
Subscribed and sworn to before me on this date: ___________________
Signature of Notary Public: _________________
City or County of _____________
My Commission expires: ________________________________________
Mail the completed certificate of compliance to:
Consumer Interests Section and Georgia Department of Revenue
Office of the Attorney General Alcohol and Tobacco Tax Division
40 Capitol Square 1800 Century Center Boulevard
Atlanta, Georgia 30334 Atlanta, Georgia 30345-3205
Form AG-03
NON-PARTICIPATING MANUFACTURER'S (NPM) APPOINTMENT OF REGISTERED AGENT FOR THE STATE OF GEORGIA AND REGISTERED AGENT'S STATEMENT
Please print or type in permanent dark ink
Sign, date, and return original to:
Office of the Attorney General for the State of Georgia
Georgia Department of Law
Consumer Interest Section
40 Capitol Square, SW
Atlanta, GA 30334
NON-PARTICIPATING TOBACCO MANUFACTURERS:
The undersigned Non-Participating Manufacturer ("NPM") _______________________ hereby appoints and authorizes __________________________________________ as its registered agent to receive service of process on our behalf. The undersigned NPM agrees to provide notice to the Office of the Attorney General for the State of Georgia ("Attorney General"), at least 30 calendar days prior to termination of the authority of the registered agent, and to provide proof to the satisfaction of the Attorney General of the appointment of a new agent at least five calendar days prior to the termination of an existing agent appointment.
Under penalty of perjury, I certify and declare that all of the statements and information contained in this Certification, including but not limited to any accompanying statements or attachments herewith, are true, accurate and complete in every particular and that I am a person authorized to bind the NPM making the Certification either under the laws of the State of Georgia or of the jurisdiction where the manufacturer resides or is organized. Any violation of the requirements of O.C.G.A. 10-13A-6 is a basis for removal of the applicant's Brand Families from the list of compliant NPMs.
** This Certification must be signed and dated by an authorized notary public. **Under penalty of perjury, I state that the information contained in this document is true and accurate.
Signature of Designee for Non-Participating Manufacturer: ____________________
Designee (Print Name): ____________________________
Title: _________________________________________________
Principal Place of Business (physical address):
_______________________________
STATE OF ______________________________}
COUNTRY OF ___________________________}
Subscribed and sworn to before me on this date: _____________
Signature of Notary Public: _______________________
City or County of _____________
My Commission expires _____________________
NAME AND ADDRESS OF GEORGIA STATE REGISTERED AGENT:
Name: _______________________________________ _____________
Street Address (Required - Must be within Georgia): _____________________________
P.O. Box: _____________________________________
City & State: _________________________ County: _____________
Zip Code: ___________________________
Telephone: __________________________________________
Facsimile: ___________________________________________
Email Address: _______________________________________
I consent to serve as Registered Agent in the State of Georgia for __________, the above-named NPM, pursuant to O.C.G.A. 10-13A-6. I understand it will be my responsibility to receive Service of Process on behalf of the NPM; to forward mail to the NPM; and to immediately notify the Office of the Attorney General if I resign or change the office address of the Registered Agent.
** This Certification must be signed and dated by an authorized notary public. **
Signature: __________________________________________
Date: _________________
Print Name: ____________________________________________
Title: _________________________________________________
STATE OF __________________________________}
COUNTRY OF _______________________________}
Subscribed and sworn to before me on this date: __________________
Signature: ______________________________________
My Commission expires: _________________________
Form AG-02
CERTIFICATE OF NON-PARTICIPATING MANUFACTURER
REGARDING QUARTERLY ESCROW PAYMENT
STATE OF GEORGIA
PART 1: TOBACCO PRODUCT MANUFACTURER'S IDENTIFICATION
Company: ____________________________
Address: _____________________________
Address: ___________________ Phone: __________________________
FAX: _________________________________
Email: ________________________ Web Address: ___________________
Name/Title of Person Completing Report: _________________________
PART 2: SALES YEAR
The sales year for this certificate is _________. The quarter being reported is (check one):
Jan.-Mar. Apr.-JuneJuly-Sept. Oct.-Dec.
PART 3: BRAND SALES
A. The number of individual cigarettes or ounces of Roll Your Own tobacco sold in Georgia during the period specified above is as follows:
Brand Name: __________________
Cigarettes or ounces sold: ____________
Brand Name: ______________________
Cigarettes or ounces sold: ____________
Brand Name: ______________________
Cigarettes or ounces sold: ____________
Brand Name: ______________________
Cigarettes or ounces sold: ____________
Total cigarettes: ____________________
Total ounces:
B. The party listed in Part 1 (check one) is is not the fabricator of the brands listed above.
C. For each brand listed above, list the name and address of any other manufacturer who fabricated the brand and the time period during which such fabrication occurred: _________
PART 4: CALCULATING THE DEPOSIT AMOUNT
Follow these steps to calculate the appropriate amount to be deposited for quarterly period:
(1) Enter the total number from Part 3 Section A above: ________
(2) Multiply that amount by the appropriate rate for the reporting period as set forth in Rule 60-1-1-.09: ____________
(3) Enter the total here: ________
The amount that must be deposited for the quarterly period will be the amount shown in Line C(3). Attach a copy of your receipt or other proof of deposit from your financial institution.
Part 5: Qualified Escrow Fund - Financial Institution
The NPM certifies that it has established, and continues to maintain, a fully funded, qualified escrow account.
Name of Institution: ____________________________________________
Address: _________________________________________________
Representative Name: ________________________________________ Phone: _______________________________
Escrow Acct No: ______________ State Account No: _____________
Total amount held in this account solely for the State of Georgia: _______
Part 6. Execution by Authorized Designee
This certification must be signed by a qualified company officer authorized to bind the applicant company.
By executing this document, I confirm that my position with the company and my actual authority to certify on behalf of the applicant meets the foregoing requirements. I understand the Georgia Attorney General may require additional information or documentation to determine if the applicant company or brands qualify for the Georgia Directory.
Under penalty of perjury, I state that the information contained in this Certification and attachments is true and accurate.
Designee (Print Name): _________________________
Title: _______________________
Signature of Designee: ___________________________
Date: _______________________
Subscribed and sworn to before me on this date: _____________
Signature of Notary Public: _____________________
City or County of _____________
My Commission expires ________________________________________
Mail the completed certificate of compliance to:
Consumer Interests Section
Office of the Attorney General
40 Capitol Square
Atlanta, Georgia 30334
Form AG-04
WHOLESALER'S MONTHLY REPORT OF "NONPARTICIPATING" AND "PARTICIPATING" MANUFACTURERS' CIGARETTES
WHOLESALE DISTRIBUTOR | PERSON COMPLETING REPORT | STATE LICENSE NO. | FOR CALENDAR MONTH/YEAR /20__ |
E-MAIL ADDRESS | STREET ADDRESS | CITY, STATE, ZIP | PHONE () |
O.C.G.A. 10-13A-7 directs the Attorney General to collect information from Wholesalers/Distributors on the number of individual cigarettes the Distributor affixed tax stamps or otherwise paid the tax due for RYO. If you stamp any cigarettes with a Georgia tax stamp, then you must list them on this Form AG-01 and file it with the Attorney General within ten days after the end of the month for which the report is filed. If you do not stamp any cigarettes during the month, this report must be filed with "NONE" reported. A complete list of authorized "Nonparticipating Manufacturers" (tobacco product manufacturers who did not sign the Master Settlement Agreement entered into on November 23, 1998) and authorized "MSA Participating Manufacturers" http://www.naag.org/tobaccopublic/libraryh.cfmand their brands can be found at www.law.ga.gov (click on "Tobacoo Manufacturer and Brand Compliance").
DIRECTIONS: PART A: NONPARTICIPATING MANUFACTUERS: List each "Nonparticipating Manufacturer" and brand family once and state the total number of individual cigarettes stamped with an orange Georgia excise tax stamp during the month and number of ounces of Roll-Your-Own tobacco you paid taxes on under the alternate method of taxation. If you receive these cigarettes from another wholesaler who has already affixed the Georgia excise tax stamp, do not list them on this report. If you do not receive or ship any cigarettes during the month from "Nonparticipating Manufacturers", write "NONE" in this section.
PART B: PARTICIPATING MANUFACTURERS: List each "MSA Participating Manufacturer" and brand family once and state the total number of individual cigarettes stamped with a blue Georgia excise tax stamp during the month and number of ounces of Roll-Your-Own tobacco you paid taxes on under the alternate method of taxation. If you receive these cigarettes from another wholesaler who has already affixed the Georgia excise tax stamp, do not list them on this report. If you do not receive any cigarettes during the month from "MSA Participating Manufacturers", write "NONE" in this section.
Please mail this report to: Georgia Department of Law, Consumer Interest Section, 40 Capitol Square, SW, Atlanta, Georgia 30334 AND a copy of this report to: Georgia Department of Revenue, Alcohol & Tobacco Division, 1800 Century Center Blvd., Room 4235, Atlanta, Georgia 30345.
A copy of all invoices covering the receipt of the cigarettes by you and the sale of the cigarettes in Georgia must be attached to this report either in hard copy or electronic form.
PART A: NONPARTICIPATING MANUFACTURERS
Nonparticipating Manufacturer's Name | Brand Name | Full Address | Country | Number of Individual Cigarettes | Ounces of Roll-Your- Own Tobacco |
PART B: PARTICIPATING MANUFACTURERS
Participating Manufacturer's Name | Brand Name | Full Address | Country | Number of Individual Cigarettes | Ounces of Roll-Your- Own Tobacco |
ALL APPLICABLE INVOICES MUST BE ATTACHED TO YOUR REPORT OR IT WILL BE RETURNED.
This certification must be signed by an officer authorized to bind your company.
By executing this document, I confirm that my position with the company and my actual authority to certify on behalf of the applicant meets the foregoing requirements.
Under penalty of perjury, I state that the information contained in this Certification and attachments is true and accurate.
Name:
Title:
Signature:
Date:
Ga. Comp. R. & Regs. R. 60-1-1-.15
O.C.G.A. Secs. 10-13A-7, 10-13A-9, 50-13-11.