Form Ctp-124 - Checklist For Certification By Non-Participating Manufacturers Or Participating Manufacturers

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State of Wisconsin
Checklist for Certification by Non-Participating Manufacturers or Participating Manufacturers
Sec. 995.12, Wis. Stats.
WHO MUST COMPLETE THIS CERTIFICATION
All foreign and domestic tobacco manufacturers requesting certification for their cigarette products, as defined in WI Stats. 995.10
(1)(d), for sale and distribution to Wisconsin consumers whether directly or indirectly through any distributor, retailer, or similar interme-
diary must complete this certification and submit it along with all forms, schedules and other documentation to the Attorney General’s
Office.
FILING DUE DATE
A complete and legible certification submission must be received by the Attorney General’s Office no later than April 30th of each year.
WISCONSIN DEPARTMENT OF REVENUE (WDOR) MANUFACTURER PERMIT
A domestic (U.S.) manufacturer of cigarette or tobacco products (for imported product, the First Importer of Record of that product into
the U.S.) must hold a valid manufacturer and/or importer permit with the Wisconsin Department of Revenue (WDOR). Application for
Cigarette and Tobacco Products Permit (CTP-129) is available on WDOR’s website at under Forms>Excise>Tobacco.
CERTIFICATION FORMS & ATTACHMENTS
When filing your certification, include a checkoff list, labeling each submission and attachment (i.e. Exhibit A–Articles of Incorporation,
etc.).
CTP-120 Certification by Participating Manufacturer
CTP-121 Certification by Non-Participating Manufacturer
CTP-122 Brand Summary List for Domestic (U.S.) Manufactured Cigarette Products
CTP-122a Schedule A: Brand Disclosure – Domestic Cigarettes
CTP-122b Schedule B: Brand Disclosure – Domestic Roll-Your-Own
CTP-122c Schedule C: Brand Disclosure – Domestic Little Cigars
CTP-123 Brand Summary List for Foreign Manufactured/Imported Cigarette Products
CTP-123a Schedule A: Brand Disclosure – Imported Cigarettes
CTP-123b Schedule B: Brand Disclosure – Imported Roll-Your Own
CTP-123c Schedule C: Brand Disclosure – Imported Little Cigars
Including Required Attached Exhibits – Be sure to label each attachment (e.g. Exhibit A, Exhibit B, etc.):
Government Issued Permit(s)/License(s) – U.S. (federal & state) and Foreign (all)
Federal TTB (Tax and Trade Bureau) reporting form 5210.5 copies for prior year (all).
Articles of Incorporation and bylaws
Certificates of Good Standing from the Secretary of State/Department of Financial Institutions or equivalent.
FTC Letter(s) of Compliance for brand label warning approval.
HHS Letter(s) of Compliance (If all brands are not listed in the HHS letter, include a notarized affidavit/statement signed by the
manufacturer, listing all brands whose full ingredients were included in the listed submission to HHS.)
Trademark Owner’s Authorization to Customs to Allow Importation of Product into the U.S.
Current Price List
Note: The Wisconsin Department of Revenue may require, along with the Letter of Direct Buy, a copy of a signed agreement
between the Manufacturer/First Importer of Record and distributors who affix Wisconsin tax stamps to the product for sale and
distribution in Wisconsin. The agreement must provide evidence of pricing to cover the MSA charge for Wisconsin sales and
should also establish reporting requirements of Wisconsin sales by the distributor to the Manufacturer/First Importer of Record.
Sample of packaging (1 package or bag each, any style).
Registered Agent’s Signed Letter of Acknowledgement (on company letterhead); Non-Participating Manufacturers only.
ASSISTANCE AND FORMS
Information, forms and assistance are available at our following office:
Write to: Wisconsin Department of Justice
Phone:
(608) 266-0180
17 W Main Street
PO Box 7857, Madison, WI 53707-7857
Fax:
(608) 267-2223
Direct Inquires to: Christopher Blythe, Assistant Attorney General, at the address listed above or phone/fax to the numbers listed above.
When ordering forms, request “Tobacco MSA Certification forms” and include the department’s form number that appears in the lower
left corner on each form (e.g. CTP-120, CTP-121, CTP-122, CTP-122a, etc.). Forms are also available on the Wisconsin Department
of Revenue’s website at under Forms>Excise>Tobacco Master Settlement Agreement (MSA).
CTP-124 (R. 3-07)
Wisconsin Department of Revenue

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