Schedule A - Participating Or Non-Participating Manufacturer Certification - Brand Disclosure

State of Wisconsin

Participating or Non-Participating Manufacturer Certification – Brand Disclosure

Schedule

A

IMPORTED Cigarette Brands

Page

of

Foreign Manufacturer Name

Certification for Sales Year

Authorized Importer’s Name

Authorized Importer’s Federal Permit No.

Authorized Importer’s WDOR Permit No.

- TI -

CIMP -

BRAND INFORMATION

IMPORTANT ALL brands manufactured and still available for sale to consumers on the U.S. market, on or after May 23, 2000, MUST be listed. Failure to disclose all brands on this application is

cause for delisting and/or denial of all attributed brands.

IMPORTED BRANDS – Brands manufactured outside the United States (U.S.) for sale in the U.S. by the manufacturer above and imported under the federal permit above.

Mark this box with an “X” to indicate brands you are requesting certification for sale and distribution in Wisconsin for this certification sales year.

X

1. Brand Name

2. Brand Style

3. MSA Status (check one)

4. Brand Reference No.

PM

NPM

A -

5. Price per Carton to Distributor for Sale & Distribution in Wisconsin:

( * ) Attach a current price list as Exhibit

Pkg. (i.e. 8/25, 10/20, 10/25, etc.) >>

$

6. Date of FTC Compliance Letter ( * )

6a. FTC Expiration Date

6b. FTC Brand Label Warning Approval Submitted to Federal Trade Commission (FTC) by:

6c. Relationship to Manufacturer

7. Date of HHS Compliance Letter ( * )

7a. HHS Expiration Date

7b. HHS Ingredient Reporting Submitted to Health & Human Services (HHS) / CDC / OSH by:

7c. Relationship to Manufacturer

March 31 of each year

8. Trademark Owner( * ): a. Legal Name >>

b. Doing Business As (DBA) Name

8c. Address:

Street Address

City

State / Province

Country

Zip Code

9. Physical Location(s) where these cigarettes are fabricated >>

Street Address

City

State / Province

Country

Zip Code

9a. Name of owner of this plant / facility (print or type)

9b. Date First Manufactured

9c. Date Last Manufactured

Reason:

Discontinued

Other

(explain)

9d. Is this the sole facility where this brand / brand style is fabricated?

Yes

No

If No, please explain and complete additional Schedule A for other location(s) and attach.

10. Exporter: a. Legal Name >>

b. Doing Business As (DBA) Name

10c. Address:

Street Address

City

State / Province

Country

Zip Code

11. Date First Exported to U.S.

12. Date Last Exported to U.S.

Reason:

Discontinued

Other

13. Date First Imported into U.S.

14. Date Last Imported into U.S.

Reason:

Discontinued

Other

(explain)

(explain)

( * ) Requires attached supporting documents.

CTP-123a (R. 12-04)

Wisconsin Department of Revenue