Form Cg-30 - Certification Of Tobacco Master Settlement Agreement Status printable pdf download

New York State Department of Taxation and Finance

CG-30

Certification of Tobacco Master Settlement

(2/11)

Agreement Status

Tobacco product manufacturer information

(type or print)

Mark an X in this box if this is an amended certification.

Legal name of manufacturer

Federal employer identification number (EIN)

Mailing address

City or town

(number and street or PO box)

State or province

Country

ZIP code

Telephone number

Fax number

Date business began in New York State

(include area code or country code)

(month, day, year)

(

)

(

)

File annually no earlier than April 16 and no later than April 30 of each year. If this is an amended certification or you are a manufacturer

first introducing products for sale in New York State (NYS), see Form CG-30-I, Instructions for Forms CG-30, CG-30.1, and CG-30.2, for

When must certifications be filed?

Forms CG-30 and CG-30.1, Information Regarding Brands Sold in New York State, must be given to an agent or distributor before the agent

may affix NYS cigarette tax stamps to that manufacturer’s cigarettes or before a distributor may sell that manufacturer’s roll-your-own (RYO)

tobacco in NYS.

Certification —

Mark an X in the applicable box to indicate that the entity is either a participating or non-participating manufacturer.

I certify that the above-named tobacco product manufacturer is:

a participating manufacturer in the Tobacco Master Settlement Agreement as defined in Public Health Law (PHL) section 1399-pp that

has generally performed its financial obligations under the Tobacco Master Settlement Agreement; or

a non-participating manufacturer as defined in the Tobacco Master Settlement Agreement in full compliance with the provisions of

PHL section 1399-pp, including all required escrow deposits.

I also certify that I have attached Form CG-30.1 listing all brands of cigarettes or RYO tobacco of the above-named tobacco product

manufacturer sold for consumption in NYS from January 1 of the previous calendar year until the date of this certification.

I also certify that if I am a manufacturer first introducing my products for sale in NYS, I have attached Form CG-30.1 listing all brands I intend

to sell in NYS effective:

(month)

(day)

(year)

If I marked box 2 above certifying that the above-named tobacco product manufacturer is a non-participating manufacturer, I also certify that

I have attached to the copies of this certification, which are sent to the Commissioner of Taxation and Finance and the Attorney General of

NYS, a copy of Form CG-30.2, Information Regarding Escrow Deposit, covering the calendar year beginning January 1 of the year prior to the

year in which this certification is made.

If this is an amended certification, and if the above-named tobacco product manufacturer is a non-participating manufacturer, I certify by marking

box 2 above that I provided a copy of Form CG-30.2 for the calendar year 20

to the Commissioner of Taxation and Finance and the Attorney

General of NYS on

(date of current certification on file).

(month)

(day)

(year)

A manufacturer who fails to file a certification, files a false certification, or otherwise violates NYS Tax Law section 480-b or 480-c may be

subject to a civil penalty of $5,000 (Tax Law section 481(1)(c)).

Under penalty of perjury, I declare that the statements contained in this certification, including any accompanying statements or attachments,

are true, correct, and complete, and that I am a person authorized to bind the manufacturer making this certification either under the laws of

NYS or of the jurisdiction where the manufacturer resides or is organized. This certification is made to induce NYS tax agents to affix NYS tax

stamps, pursuant to the Tax Law, onto the cigarettes of the above-named tobacco product manufacturer that are to be sold within NYS, or to

induce NYS tobacco distributors to sell the RYO products of the tobacco product manufacturer in NYS.

Authorized signature

Title

Printed name

Date

State of New York, County of

Subscribed and sworn to or affirmed before me this

day of

My commission expires:

Notary Public: NYS*

Seal:

*If sworn or affirmed outside of NYS, see Form CG-30-I.

Form Cg-30 - Certification Of Tobacco Master Settlement Agreement Status

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