Form 5304 - Missouri Tobacco Directory - Non-Participating Manufacturer Certification Page 2
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3B. Additional Information: Select the appropriate box(es):
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Initial or Supplemental Certification - Included with this certification is corresponding actual cigarette or RYO packaging (without tobacco)
for each brand style for which the company requests certification.
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Annual Certification (No Packaging Changes) - Corresponding actual cigarette or RYO packaging (without tobacco) has been previously
provided and there have been no changes to the packaging.
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Annual Certification (Packaging Changes or Brand Additions - There have been changes to the packaging samples previously submitted
or new brand styles have been added. Corresponding actual cigarette or RYO packaging (without tobacco) is included.
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FSC (Fire Safe Compliance ) - Attached is a letter from the Missouri State Fire Marshal’s Office indicating that the brand styles for which
the company seeks certification are FSC compliant.
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Brand Responsibility - The company identified in the Manufacturer Identification section affirms that the cigarettes or RYO brands listed
herein are to be considered the company’s cigarette and RYO brands for the purpose of calculating the company’s payments for the
purposes of
Section 196.1000
to
196.1003,
RSMo.
Select One
Response Does Not
Provided
Apply
Attach the following documents or information:
Initial Certification
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Partnership or Association: Current copy of the Certificate of Partnership or the certificate required to be filed by any
state, county or municipality.
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Corporation: 1) Current copy of the Certificate of Incorporation or other charter and 2) extracts of documents listing
the officers authorized to sign for the company.
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LLC or other entity: Current copy of the business documents filed with a state, county, or municipal entity when such
filing is required. Include a copy of any document indicating persons authorized to sign for the entity.
Organizational Documents - Required With Initial Certification Only Unless Changes
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No Changes to Organizational Documents: Organizational documents were submitted with the initial Certification
Application. There have been no changes to the organizational documents previously submitted.
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Organizational Documents Have Changed: There have been changes to the organizational documents previously
submitted. Copies of all updated documents are attached.
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Company Officers and Owners: Provide a list of all company officers and company owners (all persons with an equity
interest of 10% or more in the company). Include name, address, phone number and e-mail address.
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Affiliates: Provide a list of all company Affiliates that also manufacture, import, distribute, or sell cigarettes or
Roll Your Own (RYO). Include the name, address and contact information for each Affiliate.
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Marketing Information: For each brand family, list the name, address and contact information for each Missouri
wholesaler through which the company intends to sell cigarettes or RYO in Missouri.
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Agreements with Participating Manufacturers: Identify every agreement between the company and any Participating
Manufacturer (“PM”) or PM Affiliate that relates to the making, importing, distribution, transportation, or sale of each
Brand Family.
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Agreements Regarding Compliance with the Qualified Escrow Statute: List every Brand Family that is the subject
of any agreement regarding compliance with a Qualified Escrow Statute.
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Health Warning Rotation Plan: For each Brand Family, list the name and address of the entity that filed cigarette health
warning rotation plan with the Federal Trade Commission. Attach the Federal Trade Commission’s written approval of
the company’s annual Cigarette Health Warning Rotation Plan. Applies only to cigarettes.
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Ingredient Report: For each Brand Family, list the name and address of the entity that submitted the ingredient reporting
information to the U.S. Secretary of Health and Human Services as required by the Federal Cigarette Labeling
and Advertising Act. Attach copies of all Certificates of Compliance received from the U.S. Secretary of Health
and Human Services for the company’s annual ingredient reporting required by the Federal Cigarette Labeling
and Advertising Act (15 USC § 1335a). Applies only to cigarettes.
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Imported Cigarettes: If company sells or intends to sell cigarettes or RYO brands that are not manufactured in the
United States, provide the following:
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A copy of the sworn statement of the original manufacturer that it will timely submit ingredient information to
the Secretary of Health and Human Services as required by 19 USC §1681a(c)(1). Cigarettes Only.
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A copy of the importer’s certificate under penalty of perjury as required by 19 USC §1681a(c)(2) regarding
the precise format of warnings and the rotation plan for health warning. Cigarettes Only.
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A copy of the trademark holder’s certificate under penalty of perjury that it has not withdrawn consent to
import into the United States as required by 19 USC §1681a(c)(3)(A) or a copy of the importer’s certificate
under penalty of perjury that the trademark owner has not withdrawn consent to import into the United
States as required by USC §1681a(c)(3)(B).
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Internet or Mail Order Sales: If company intends to sell any Cigarettes (including RYO tobacco) by mail order or via
the Internet.
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Security Interest: Please identify any person or entity, other than a regulated financial institution, with a security interest
or security interests in assets of the company that exceed 10% of the value of all of the company’s gross assets (i.e., not
counting assets after deducting liabilities). Attach all security agreements and financing statements for the security
interests, and provide a listing of where the financing statements have been filed to perfect the security interests.
Form 5304 (Revised 01-2015)
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