CHECKLIST FOR COMPLETING CERTIFICATION FORM
Pursuant to SDCL 10-50B, the South Dakota Department of Revenue may require a tobacco product manufacturer to
submit any additional information necessary to enable the South Dakota Department of Revenue to determine whether a
manufacturer is in compliance.
A.
Checklist for Participating Tobacco Product Manufacturers
Parts 1, 2A and 9 are completed in their entirety;
FTC Approval Letter (cigarettes) & CDC Compliance Letter (cigarettes) are attached (Part 2A)
Affidavit is signed by the authorized designee of the tobacco product manufacturer as established by the
MSA or MSA Amendment by which the manufacturer joined the MSA, and affidavit is notarized (Part 9);
B.
Checklist for Non-participating Manufacturers
All parts are completed except Part 2A;
Packaging is attached (Part 2B);
TTB Permit, FTC Approval Letter (cigarettes) & CDC Compliance Letter (cigarettes) are attached (Part 2B);
Trademark information is attached (Part 4);
Organization information is attached (Part 5);
If registered agent has been appointed, letter from agent accepting appointment is attached (Part 6);
Current escrow agreement and any attachments and amendments are attached (Part 7);
Proof of escrow deposit for previous year’s sales are attached (Part 7);
Current escrow account statement from financial institution for SD sub-account is attached (Part 7);
Consent to suit provision and affidavit are signed by an authorized officer of the Non-participating
Manufacturer and notarized (Parts 8 & 9);
Copies of all other requested documents are attached if applicable (Part 2B).
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