Form Tt-19-Npm - Tobacco Product Manufacturer Certification For Non-Participating Manufacturers Page 9
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9Part 10: 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 Non-Participating Manufacturer 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; 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; (4) the Tobacco Product Manufacturer hereby submits
itself to the jurisdiction of the Circuit Court of the City of Richmond, Virginia for purposes of
all litigation arising out of this certification or the sale of tobacco products in Virginia; (5) 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; (6) by filing this certification, the Tobacco
Product Manufacturer accepts escrow responsibility for all Cigarettes and RYO product sold
in Virginia under the brand names certified herein; (7) 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 (8) I am a qualified company officer authorized to bind the
Tobacco Product Manufacturer making this Certification.
Name:
Title:
Phone:
Fax:
Email:
Date:
Signature:
Notary:
State and Nation of:
City/County of:
Subscribed and sworn to before me on this date:
Signature:
My commission expires:
Mail this original fully executed
Mail a copy of the Certification to:
Certification, Including attachments
Tobacco Tax Unit
and supporting documents to:
Virginia Department of Taxation
Tobacco Section
P.O. Box 715
Office of the Attorney General
Richmond, Virginia 23218-0715
900 East Main Street
Additional information is available at:
Richmond, Virginia 23219
Page 9 of 9
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