Form 1783 - South Dakota Tobacco Product Manufacturer Complementary Legislation Certification Page 8
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12PART 9: AFFIDAVIT OF TOBACCO PRODUCT MANUFACTURER
An authorized officer of the tobacco manufacturer MUST sign this form and check one box below. This
form MUST be notarized.
PARTICIPATING MANUFACTURER: Under penalty of criminal prosecution under the laws of South Dakota, I
state that the tobacco product manufacturer named in Part 1A, as of the date of this certification, is a
Participating Manufacturer in full compliance with SDCL ch. 10-50B, 10-50-72 et seq. and any rules promulgated
pursuant thereto.
I am the authorized designee for the Participating Manufacturer, as established in the MSA or MSA Amendment
by which the Participating Manufacturer joined the MSA, and I am signing as such.
I understand that the SD Department of Revenue may require additional information and/or documentation to
determine if applicant qualifies for listing on the South Dakota Directory.
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.
Under penalty of criminal prosecution under the laws of South
NON-PARTICIPATING MANUFACTURER:
Dakota, I state that the tobacco product manufacturer named in Part 1A, as of the date of this certification, is a
Non-participating Manufacturer in full compliance with SDCL ch. 10-50B, 10-50-72 et seq. and any rules
promulgated pursuant thereto.
This certification must be signed by a qualified company officer authorized to bind the applicant company. My
position with the company and my actual authority to certify on behalf of the applicant meets the foregoing
requirements.
I understand that the SD Department of Revenue may require additional information and/or documentation to
determine if applicant qualifies for listing on South Dakota Directory.
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.
By signing this affidavit on behalf of the applicant company I understand that the company is required to comply with state
and federal laws concerning the sale of tobacco products.
Name of Officer of Tobacco Product Manufacturer (Print Name)
Title
Signature of Officer
Date
Subscribed and sworn to this date:
County of:
Signature of Notary Public:
Notary Commission expires:
8
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