Form Tt-19-Pm - Tobacco Product Manufacturer Certification For Participating Manufacturers Page 3
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3FORM TT-19-PM
Part 4: Affidavit of Tobacco Product Manufacturer (must be executed by an authorized officer)
Under penalty of perjury, I state that (1) the Tobacco Product Manufacturer, as of the date of this Certification, is
a Participating Manufacturer performing its financial obligations under the MSA and in full compliance with all
applicable sections of Va. Code §§ 3.1-336.1 through 3.1-336.16; (2) I have examined this Certification, including
attachments and supporting documents and, to the best of my knowledge and belief, this Certification, including
attachments and supporting documents, is true, correct and complete; (3) I understand that the Tobacco Product
Manufacturer is required to comply with state and federal laws concerning the sale of tobacco products, and that
failure to do so may constitute grounds for exclusion from the Virginia Tobacco Directory; (4) the Tobacco
Product Manufacturer hereby waives any claim or defense of sovereign immunity with respect to any litigation
brought by the Commonwealth of Virginia arising out of this certification or the sale of tobacco products in
Virginia; (5) I understand that the cigarette brands and brand families listed herein are to be deemed the
cigarettes of this Manufacturer for purposes of the Master Settlement Agreement; (6) I understand that the
Attorney General may require additional information and/or documentation to determine if the Tobacco Product
Manufacturer qualifies for listing in the Virginia Tobacco Directory and to determine that the assurances herein
are true, correct, and complete; I agree to provide such information upon request, and I understand that failure to
do so may constitute grounds for exclusion from the Virginia Tobacco Directory; and (7) I am a qualified company
officer authorized to bind the Tobacco Product Manufacturer making this Certification.
Name:
Title:
Phone:
Fax:
Email:
Date:
Signature:
Notary:
City/County of
, State and Nation of ________________________
Subscribed and sworn to before me on this date:
Signature:
My commission expires:
Mail this original fully executed Certification, including attachments and supporting documents to:
Tobacco Unit
Office of the Attorney General
900 East Main Street
Richmond, Virginia 23219
Mail a copy of the Certification to:
Tobacco Tax Unit
Virginia Department of Taxation
P.O. Box 715
Richmond, Virginia 23218-0715
Additional information is available at:
Rev. (12/06)
Page 3 of 3
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