Form Tt-19-Npm - Tobacco Product Manufacturer Certification For Non-Participating Manufacturers Page 4
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The Tobacco Product Manufacturer (or any person or entity listed in the Certification) has
been denied a permit or license, or has been denied any other authorization to engage in
business relating to the sale of cigarettes by any government entity (federal, state, local or
foreign) or had such permit, license or other authorization revoked, suspended, or otherwise
terminated.
• If the above is applicable, for each such denial, revocation, suspension or termination
of a permit, license or other authorization a copy of any case decision and the following
information must be attached to the Certification: (1) the name of the person or entity that had
such permit, license or other authorization revoked, suspended or otherwise terminated; (2)
the governmental entity (federal, state, local or foreign) that denied, suspended, or revoked
such permit, license, or other authorization; (3) the case number; and, (4) the name and
address of the government attorney or official that brought the action.
□
The Tobacco Product Manufacturer (or any person or entity listed in the Certification) has
been convicted of any crime under federal, state or foreign law in connection with the sale of
cigarettes.
• If the above is applicable, for each such conviction a copy of any case decision and the
following information must be attached to the Certification (1) the name of the person or
entity convicted; (2) the governmental entity (federal, state local, or foreign) that prosecuted
the action; (3) the case number; and, (4) the name and address of the government attorney
or official that prosecuted the action.
□
The Tobacco Product Manufacturer (or any person or entity listed in the Certification) has
been involved as an officer or owner of any other Tobacco Product Manufacturer.
• If the above is applicable, the name of the other Tobacco Product Manufacturer(s) must be
provided and a complete description of the involvement with such entity must be attached
to the Certification. If any such other Tobacco Product Manufacturer has ever been sued by
any state for alleged failure to fully and properly comply with its obligations under the Master
Settlement Agreement, the Virginia Tobacco Escrow Statute or any state tobacco escrow
statute, for each such occurrence a copy of any case decision and the following information
must be attached to the Certification: (1) the name of the entity that failed to comply with its
obligations under the Master Settlement Agreement, the Virginia Tobacco Escrow Statute
or any state tobacco escrow statute; (2) the Brand Family(s) for which the entity failed to
comply with its obligations; (3) the amount of any unpaid obligation; and (4) a complete
description of the current status of the matter.
□
The Tobacco Product Manufacturer (or any person or entity listed in the Certification) has
been denied listing in any other state tobacco directory.
• If the above is applicable, for each such denial a copy of any case decision and the following
information must be attached to the Certification: (1) the name of the person or entity denied
listing in a state tobacco directory; (2) the Tobacco Product Manufacturer and Brand Family(s)
denied listing; and (3) the state where listing was denied.
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