Form Ctp-123 - Participating Or Non-Participating Manufacturer Certification - Brand Summary

State of Wisconsin

Participating or Non-Participating Manufacturer Certification - Brand Summary

Foreign Manufactured Cigarettes IMPORTED into the United States (U.S.) for Sale in the U.S.

Page

of

Foreign Manufacturer Name

Authorized Importer Name(s)

Certification for Sales Year

Authorized Importer’s Federal Permit No. Authorized Importer’s WDOR Permit No.

- TI -

CIMP -

TIMP -

COMPLETE BRAND SUMMARY LIST

List all brands manufactured by you and available for sale to consumers on the U.S. market, on or after May 23, 2000. Failure to disclose all brands on this certification is cause for delisting and/or denial of

listing for all attributed brands. NOTE: Following the initial certification, the manufacturer must update its list thirty (30) days prior to any addition to, modification of, its Brand Families by executing and

delivering a supplemental Certification Form to the Attorney General and the Department of Revenue.

Cigarette: As defined in 995.10(1)(d), (Wis. Stats.)

Brand Family: As defined in 995.12(1)(a), (Wis. Stats.)

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. Attach all corresponding

Brand Certification Schedules in alpha/numeric order (i.e. A-1, A-2, B-1, B-2, C-1, C-2, etc.).

Instructions: List all brands in alphabetical order for each category. A Cigarettes [first]; B Roll-Your-Own Tobacco (RYO) [next]; and C Little Cigars [last].

Brand

Product Type

*

**

***

Reference No.

Cigarette [first]

X

[Enter A-1,

RYO [next]

Brand Family

Other Manufacturers

Brand Name

Brand Style

A-2, B-1, ...]

Little Cigars [last]

(e.g. King, 100’s, Light, etc.)

*

Mark with an “X” each brand that you request brand certification for sale of that product.

Include with your certification, one package or one bag of each brand (any style) of Cigarettes, RYO, or Little Cigars you are seeking to certify.

**

A Participating Manufacturer shall not include a Brand Family in its certification, unless the Participating Manufacturer affirms that the Brand Family is to be deemed to be its cigarettes for the purpose of

calculating payments under the Master Settlement Agreement for the relevant year, in the volume and shares determined pursuant to the Master Settlement Agreement. Nothing in this Certification shall

limit or otherwise affect the State’s right to maintain that a Brand Family constitutes cigarettes of a different tobacco product manufacturer for purposes of calculating payment under the Master Settlement

Agreement.

***

Identify other manufacturers including, but not limited to, any other current or previous fabricators of any brands or brand families listed on this certification.

CTP-123 (R. 3-07)

Wisconsin Department of Revenue