State Of Arizona Tobacco Product Manufacturer Arizona


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STATE OF ARIZONA TOBACCO PRODUCT MANUFACTURER
ARIZONA CIGARETTE DIRECTORY CERTIFICATION PURSUANT TO A.R.S. § 44-7111 (CALENDAR YEAR 2022)
GENERAL INFORMATION
Definitions:
1. “Brand Family” means all styles of Cigarettes sold under the same trade mark and differentiated from one another by means of additional modifiers or descriptors, including, but not limited to, “menthol”, “lights”, “kings” and “100s”, and includes any brand name (alone or in conjunction with any other word), trademark, logo, symbol, motto, selling message, recognizable pattern of colors, or any other indicia of product identification identical or similar to, or identifiable with, a previously known brand of Cigarettes. [A.R.S. § 44-7111(2)(a)].
2. “Cigarette” has the same meaning prescribed in A.R.S. § 44-7101(2)(d).
3. “Directory” means the Directory described in A.R.S. § 44-7111(3)(b).
4. “Distributor” has the same meaning prescribed in A.R.S. § 42-3001.
5. “Master Settlement Agreement” has the same meaning prescribed in A.R.S. § 44-7101(2)(e).
6. “Non-Participating Manufacturer” means any Tobacco Product Manufacturer that is not a Participating Manufacturer. [A.R.S. § 44-7111(2)(g)].
7. “Participating Manufacturer” has the same meaning prescribed in Section II(jj) of the Master Settlement Agreement and all amendments thereto. [A.R.S. § 44-7111(2)(h)].
8. “Qualified Escrow Fund” has the same meaning prescribed in A.R.S. § 44-7101(2)(f).
9. “Resident Agent” has the same meaning prescribed in A.R.S. § 44-7111(4)(a).
10. “Tobacco Product Manufacturer” has the same meaning prescribed in A.R.S. § 44-7101(2)(i).
11. “Units Sold” has the same meaning prescribed in A.R.S. § 44-7101(2)(k).
When is This Certification Due?
This Certification must be executed and delivered any time a Tobacco Product Manufacturer seeks to be listed in the Directory. [A.R.S. § 44-7111(3)]. Thereafter, the Certification must be executed and delivered no later than April 30th of each year. [A.R.S. § 44-7111(3)(a)]. In addition, a Tobacco Product Manufacturer must execute and deliver a Supplemental Certification to the Arizona Attorney General when requesting any addition to or modification of its Brand Families. Please note that the Supplemental Certification requesting the addition or modification does not relieve the Brand Families from the prohibitions set forth in A.R.S. §§ 44-7111(3)(c) and 6(d) until after the request is approved by the Attorney General and the addition or modification to the Brand Families is reflected on the Directory itself. [A.R.S. § 44-7111(3)(a)(1)-(2)]. Also, all waivers of sovereign immunity, importer declarations, and bond certifications MUST be submitted as attachments to an Initial, Annual, or Supplemental Certification as required under A.R.S. § 44-7111. [A.R.S §§ 44-711 3(e), (h)]. Finally, as to all Certifications required under A.R.S. § 44-7111, if the Certification is rejected by the Attorney General due to incompleteness or incorrectness, the Tobacco Product Manufacturer may not submit supplemental documentation to try to cure the defect. Instead, the Tobacco Product Manufacturer must execute and deliver an entirely new Certification to the Attorney General. [A.R.S. § 44-7111(3)(a)].

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The Completed Certification Must be Delivered to:

The Office of the Attorney General Tobacco Enforcement Unit 2005 North Central Ave. Phoenix, AZ 85004-2926

Records Retention Requirement:

Tobacco Product Manufacturers shall maintain all invoices, documentation of sales, and other information relied upon for the Certification for a period of five (5) years, unless otherwise required by law to maintain them for a greater period of time. [A.R.S. § 44-7111(3)(a)(5)].

Compliance With Other Statutes:

The fact that a Tobacco Product Manufacturer or Brand Family is listed in the Directory merely means that the Tobacco Product Manufacturer and/or Brand Family have been approved pursuant to A.R.S. § 44-7111(3). It does not mean that they are compliant with other Arizona State laws applicable to the sale and/or distribution of Cigarettes, such as A.R.S. § 42-3210. Importantly, a Non-Participating Manufacturer’s failure to comply with any applicable state or federal law, including, but not limited to, A.R.S. §§ 44-7101 and 44-7111, is grounds for its removal from the Directory. [A.R.S. § 447111(3)(b)(i)].

SPECIFIC INSTRUCTIONS

Part 1:

Identification of the Purpose of the Certification: Identify whether the Certification being submitted is an Initial, Annual, or Supplemental Certification. In regard to Initial and Annual Certifications, this entire form must be completed.

In the event the Tobacco Product Manufacturer is submitting a Supplemental Certification, the Certification need only be completed with regard to the reason for the Supplemental Certification (as well as Parts 1, 2, & 8). Any change to the information included in the Certification on file requires the filing of a Supplemental Certification. Such reasons include, but are not limited to: a change in Resident Agent; an amendment to the Escrow Agreement; a modification to the Non-Participating Manufacturer’s bond; or a request to list an additional Brand Family(ies). For example, if the Tobacco Product Manufacturer is only requesting the removal of a Brand Family(ies), it need only complete Parts 1, 2, 7 & 8 of this Certification.

Part 2:

Tobacco Product Manufacturer Identification: Identify the Tobacco Product Manufacturer's name, physical address, mailing address, telephone and fax numbers, and the name, title, phone, and email address of the person completing the Certification. Next, certify whether the Tobacco Product Manufacturer, as of the date of this Certification’s execution, is a: (i) Participating Manufacturer; or (ii) Non-Participating Manufacturer in full compliance with A.R.S. § 44-7101(3)(b).

Part 3:

Brand Family Identification: Only the Brand Families listed in the Certification may be included in the Directory.

A Tobacco Product Manufacturer that is not currently listed in the Directory must submit an Initial Certification subject to the same requirements and review process set forth in A.R.S. § 44-7111 for Annual Certifications. The Tobacco Product Manufacturer’s Brand Families remain subject to the prohibitions set forth in A.R.S. §§ 447111(3)(c) and 6(d) until the request is formally approved by the Attorney General and the modification is reflected on the Directory itself. [A.R.S. § 44-7111(3)(a)(6)].

A. Participating Manufacturers

A Participating Manufacturer shall list its Brand Families. [A.R.S. § 44-7111(3)(a)(1)]. A Participating

Manufacturer may not include a Brand Family in its Certification unless it affirms that the Brand Family is to be

deemed its Cigarettes for purposes of calculating its payments under the Master Settlement Agreement for the

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relevant year, in the volume and shares determined pursuant to the Master Settlement Agreement. [A.R.S. § 447111(3)(a)(4)].

The Participating Manufacturer shall update its list of Brand Families thirty (30) calendar days prior to any addition to, or modification of, its Brand Families by executing and delivering a Supplemental Certification to the Attorney General. [A.R.S. § 44-7111(3)(a)(1)].

B. Non-Participating Manufacturers

1. A Non-Participating Manufacturer shall: (i) include a list of all its Brand Families that it is requesting be listed
in the Directory and the corresponding Units Sold during calendar years 2021 and 2022; (ii) identify by name and address any other manufacturer of its Brand Families in 2021 or 2022; and (iii) identify whether each brand listed in the 3.B chart is a Cigarette or roll-your-own tobacco. [A.R.S. § 44-7111(3)(a)(2)]. A Non-Participating Manufacturer may not include a Brand Family in its Certification unless it affirms that the Brand Family is to be deemed its Cigarettes for purposes of A.R.S. § 44-7101(3)(b). [A.R.S. § 447111(3)(a)(4)].

2. The Non-Participating Manufacturer shall, for both 2021 and 2022, provide a list of all the residential and nonresidential Arizona-licensed distributors who: 1) the Applicant sold Cigarettes to; or 2) the Applicant believes or has reason to believe purchased or received any of the Applicant’s Cigarettes from another source. [A.R.S. § 44-7111(3)(a)(2)].

The Non-Participating Manufacturer shall deliver a Supplemental Certification to the Attorney General to request any addition to, or modification of, its Brand Families, and the prohibitions set forth in A.R.S. §§ 447111(3)(c) and 6(d) remain in effect until the brand is listed in the Directory. [A.R.S. § 44-7111(3)(a)(2)].

Part 4: Non-Participating Manufacturer Certification

B. Resident Agent for Service of Process

Certify whether the Non-Participating Manufacturer is: (i) domiciled in the State of Arizona; (ii) a non-resident or foreign Non-Participating Manufacturer that has registered to do business in Arizona as a foreign corporation or business entity; or (iii) a Non-Participating Manufacturer that has appointed a Resident Agent for service of process, pursuant to A.R.S. § 44-7111(4), on whom all process, and any action or proceeding against it concerning or arising out of the enforcement of A.R.S. §§ 44-7101 and 44-7111, may be served in any manner authorized by law. [A.R.S. § 44-7111(4)(a)].

If the Non-Participating Manufacturer has appointed a Resident Agent for service of process, please supply the information requested on the Certification and then attach as an exhibit a completed Arizona Resident Agent Statement form, found at https://www.azag.gov/consumer/tobacco/forms.

Note: The Non-Participating Manufacturer shall provide notice to the Attorney General thirty (30) days prior to the termination of the authority of a Resident Agent and shall further provide proof, to the satisfaction of the Attorney General, of the appointment of a new Resident Agent not less than five (5) calendar days prior to the termination of the existing agency appointment. [A.R.S. § 44-7111(4)(b)]. In the event a Resident Agent terminates an agency appointment, the Non-Participating Manufacturer shall notify the Attorney General of the termination within five (5) calendar days and shall include proof, to the satisfaction of the Attorney General, of the appointment of a new Resident Agent. [A.R.S. § 44-7111(4)(b)].

C. Qualified Escrow Fund – Financial Institution

Identify: (i) the name, mailing address, and telephone number of the financial institution where the NonParticipating Manufacturer has established a Qualified Escrow Fund pursuant to A.R.S. § 44-7101(3)(b); (ii) the account number of such Qualified Escrow Fund and any sub-account number for the State of Arizona [A.R.S. § 44-7111(3)(a)(3)(D)]; and (iii) the name, phone number, and email address of a representative of the financial

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Part 5: Part 6:

institution who is knowledgeable about the Qualified Escrow Fund. Also, state whether the Escrow Agreement has been approved by the Attorney General.
Either: (i) attach as an exhibit a copy of the Non-Participating Manufacturer's Escrow Agreement; or (ii) state that the Escrow Agreement in the form attached to the most recent Certification, submitted pursuant to A.R.S. § 44-7111 and deemed complete and acceptable by the Attorney General, is still in full force and effect without amendment or modification.
D. Escrow Deposit/Withdrawal History for Arizona
Attach as an exhibit copies of records of the financial institution establishing: (i) the amount the NonParticipating Manufacturer deposited in the Qualified Escrow Fund for Units Sold in Arizona during 2021 as well as the date and amount of each deposit; (ii) the amount and date of any withdrawal or transfer of funds the Non-Participating Manufacturer made at any time from the Qualified Escrow Fund into which it ever made escrow payments pursuant to A.R.S. § 44-7101; and (iii) the total amount of funds held in escrow for the benefit of the State of Arizona. Note: All withdrawals must comply with A.R.S. § 44-7101(3)(b)(2) and verification of compliance must be provided.
In the alternative to providing the foregoing information, the Applicant may certify that it has not deposited, nor has it been required to deposit during any year, any money into a Qualified Escrow Fund for the benefit of the State of Arizona, pursuant to A.R.S. § 44-7101, on account of Units Sold in Arizona.
E. Bond Requirement
Every Non-Participating Manufacturer must post a bond for the exclusive benefit of Arizona. [A.R.S. § 447111(3)(d)]. Information about Arizona’s surety bond requirement can be found at https://www.azag.gov/consumer/tobacco/faq. Pick one of the two options and attach the form and bond if necessary.
F. Immunity Waivers
Please select the waiver option that applies (every Non-Participating Manufacturer must choose one of the waiver options) and attach the applicable form if necessary.
Non-Participating Manufacturer Certification – Status as a Tobacco Product Manufacturer: The Applicant must respond completely and accurately to the questions in Part 5 concerning the Applicant’s status as the Tobacco Product Manufacturer of the Brand Families listed in the Certification. The Applicant must re-print the questions, answer each, and then attach the completed document as an exhibit which shall be incorporated into Part 5 of this Certification as if set forth fully therein. The information is provided as the Applicant’s sworn statement under penalty of perjury. All materials provided in support of the Applicant’s responses to the questions in Part 5 which are written in a language other than English must be translated into English in order to be considered.
Participating and Non-Participating Manufacturers – PACT Act, Fire-Safe, and Flavored Cigarettes: Part 6 applies to both Participating and Non-Participating Manufacturers. With regard to the Applicant’s non-direct Cigarette sales activity, mark which paragraph applies or provide a statement as to why none apply, labeled and attached as an exhibit. State whether the Applicant is registered with the United States Attorney General and the Department of Revenue as required under the PACT Act. Provide as an exhibit the proof that the Tobacco Product Manufacturer’s Brand Families, certified in Part 3.A or 3.B, are in compliance with Arizona’s Reduced Cigarette Ignition Propensity Statute. Also, identify whether the Tobacco Product Manufacturer’s Brand Families, certified in Part 3.A, are in compliance with flavored cigarette restrictions contained in 21 U.S.C.A. § 387(g). Acknowledge that certain laws apply to sales of Cigarettes in Arizona.

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Part 7: Part 8:

Removal of Brand Families: Part 7 need only be completed if the Tobacco Product Manufacturer is already listed in the Directory and is requesting the removal of one or more of its Brand Families listed in the Directory. Please list the Brand Family(ies) that the Tobacco Product Manufacturer is requesting be removed from the Directory. If the Tobacco Product Manufacturer is only requesting the removal of a Brand Family(ies), please only complete Parts 1, 2, 7 & 8 of this Certification.
Execution by Authorized Designees: The Designee executing this Certification must be an employee of the Tobacco Product Manufacturer identified in Part 2, and authorized to execute this Certification on the Manufacturer's behalf. The Designee’s name and title must be printed, and the Certification executed, in the presence of an authorized notary. All signatures and the notary seal must be original. Photocopies, email scans, or facsimile transmissions of Part 8 are unacceptable, and will result in the Certification being rejected as incomplete.

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STATE OF ARIZONA TOBACCO PRODUCT MANUFACTURER CERTIFICATION PURSUANT TO A.R.S. § 44-7111 (CALENDAR YEAR 2022)

NOTICE:

This Certification must be filled out completely and accurately. All documentation submitted in support of this Certification must be clearly referenced, conspicuously labeled, and attached. Failure to respond to each question, or to properly reference, label, and attach supporting documentation may result in the Certification being rejected as incomplete.

Part 1: Identification of the Purpose of the Certification

Indicate the purpose for which this Certification is being submitted (check one of the three options below):

________ Initial Certification (i.e., for Tobacco Product Manufacturers not currently listed in the Directory). The entire Certification must be completed.

________ Annual Certification (i.e., for Tobacco Product Manufacturers currently listed in the Directory and due annually by April 30th). The entire Certification must be completed.

________

Supplemental Certification (Refer to instructions in Part 1 of Page 2 to determine if a Supplemental Certification is appropriate.) The Certification need only be completed with regard to the reason for the Supplemental Certification (as well as Parts 1, 2 & 8). For example, if the Tobacco Product Manufacturer is requesting the removal of a Brand Family(ies) only, it need only complete Parts 1, 2, 7, & 8.

Part 2: Tobacco Product Manufacturer Identification

Tobacco Product Manufacturer: ______________________________________________________________________ Physical Address (no post office box):_________________________________________________________________ Mailing Address: _________________________________________________________________________________ Phone: _________________________________________ Fax: ___________________________________________ Email: _________________________________________ Website Address: _________________________________ Name/Title of Person Completing Certification: _________________________________________________________ Phone of Person Completing Certification: ______________________________ Email: ___________________________

The Tobacco Product Manufacturer identified above is, as of the date on this Certification (check one):

________ A Participating Manufacturer under the Master Settlement Agreement.

________ A Non-Participating Manufacturer in full compliance with A.R.S. § 44-7101(3)(b).

Part 3: Brand Family Identification

A. Participating Manufacturers (check one of the two statements below):

________

The Participating Manufacturer, identified in Part 2, has listed its Brand Families in the table below, each of which the Participating Manufacturer hereby affirms are to be deemed its Cigarettes for purposes of calculating its payments under the Master Settlement Agreement for the relevant year, in the volume and shares determined pursuant to the Master Settlement Agreement.

________

As an alternative to filling out the table on the following page, the Participating Manufacturer hereby
attaches as Exhibit ________ (insert exhibit number) a list of its Brand Families, each of which the Participating Manufacturer hereby affirms is to be deemed its Cigarettes for purposes of calculating its payments under the Master Settlement Agreement for the relevant year, in the volume and shares determined pursuant to the Master Settlement Agreement. (Note: The attached exhibit must be conspicuously labeled as an exhibit. It shall be deemed incorporated into Part 3.A as if set forth fully herein.)

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Brand Families

B. Non-Participating Manufacturers

1. Check one of the two statements:

________

The Non-Participating Manufacturer, identified in Part 2, has listed its Brand Families in the table below, each of which the Non-Participating Manufacturer affirms is to be deemed its Cigarettes for purposes of A.R.S. § 44-7101(3)(b).

________

As an alternative to filling out the table below, the Non-Participating Manufacturer hereby attaches as
Exhibit ________ (insert exhibit number) a list of Brand Families, each of which the Non-Participating Manufacturer affirms are to be deemed its Cigarettes for purposes of A.R.S. § 44-7101(3)(b), and the other information required in the table below. (Note: The attached exhibit must be conspicuously labeled as an exhibit. It shall be deemed incorporated into Part 3.B as if set forth fully herein.)

Brand Family

Units Sold in 2021

Units Sold Thus Far in
2022

Name and Address of Other Manufacturers of Brand Family
in Either 2021 or 2022

Cigarette or RollYour-Own

2. Check one of the two statements:

________

The Non-Participating Manufacturer identified in Part 2 has listed in the table below, for both 2021 and 2022, a list of all the residential and nonresidential Arizona-licensed distributors who: 1) the Applicant sold Cigarettes to; 2) the Applicant believes or has reason to believe purchased or received any of the Applicant’s
Cigarettes from another source; and/or 3) the Applicant has reason to believe WILL purchase or receive any of the Applicant’s Cigarettes, whether directly from the Applicant or from another source, for purposes of A.R.S. § 44-7111(3)(a)(2).

________

As an alternative to filling out the table below, the Non-Participating Manufacturer hereby attaches as
Exhibit ________ (insert exhibit number) a list, for both 2021 and 2022, of all the residential and nonresidential Arizona-licensed distributors who: 1) the Applicant sold Cigarettes to; 2) the Applicant believes or has reason to believe purchased or received any of the Applicant’s Cigarettes from another
source; and/or 3) the Applicant has reason to believe WILL purchase or receive any of the Applicant’s Cigarettes, whether directly from the Applicant or from another source, for purposes of A.R.S. § 447111(3)(a)(2). (Note: The attached exhibit must be conspicuously labeled as an exhibit. It shall be deemed incorporated into Part 3.B as if set forth fully herein.)

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2021

2022

Part 4: Non-Participating Manufacturer Certification

A. Exhibits and Attachments – initial below

_______

By initialing here, the tobacco product manufacturer acknowledges that the attached exhibits and attachments and their contents are current, complete, and accurate.)

B. Resident Agent for Service of Process (check one of the options below):

1.

________

The Non-Participating Manufacturer, identified in Part 2, is domiciled in the State of Arizona.

2.

________

The Non-Participating Manufacturer, identified in Part 2, is a non-resident or foreign Non-

Participating Manufacturer that has registered to do business in the State of Arizona as a foreign

corporation or business entity.

3.

________

The Non-Participating Manufacturer, identified in Part 2, has appointed and continues to engage,

the Resident Agent identified on the Arizona Resident Agent Statement attached hereto at Exhibit

_____ (insert exhibit number; the attached exhibit must be conspicuously labeled as an exhibit; it

shall be deemed incorporated into Part 4.B as if set forth fully herein) for service of process on

which all process, and any action or proceeding against it concerning or arising out of the

enforcement of A.R.S. §§ 44-7101 & 44-7111, may be served in any manner authorized by law.

Proof of appointment and availability of the Resident Agent must be provided using Arizona’s

Resident Agent Statement form, found at https://www.azag.gov/consumer/tobacco/forms.

________

(Not an option if the form has changed - please check online): In the alternative, the Tobacco Product Manufacturer, identified in Part 2, hereby swears its Resident Agent Statement attached to the Certification signed on ________________ (enter date Certification was signed by month/day/year) and submitted pursuant to A.R.S. § 44-7111, which was deemed complete and accepted by the Attorney General, is still in full force and effect without amendment or modification. (When choosing this option, the Tobacco Product Manufacturer need not attach as an exhibit a copy of its Resident Agent Statement).

C. Qualified Escrow Fund

1. Financial Institution

Name of Institution: _____________________________________________________________________________ Mailing Address: _______________________________________________________________________________ Representative Name: ___________________________Representative Phone: _____________________________ Representative Email: ___________________________________________________________________________ Qualified Escrow Fund Account No: ____________________ Arizona Sub-account No: ______________________

2. If the above-referenced financial institution is not the original Escrow Agent for the Qualified Escrow Fund created and maintained for the benefit of Arizona, please provide: (i) the names, phone numbers, and email addresses for all previous Escrow Agents; and (ii) the date of removal of each. Information regarding any former Escrow Agents is

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attached hereto as Exhibit ________ (insert exhibit number). (Note: The attached exhibit must be conspicuously labeled as an exhibit. It shall be deemed incorporated into Part 4.C as if set forth fully herein.)

3. Are the funds that are deposited in the above-referenced Qualified Escrow Fund for the benefit of Arizona deposited in a segregated sub-account, separate and apart from any funds deposited for the benefit of any other beneficiary? ______ Yes ______ No (Check one.)

If the Applicant answered ‘No’, the Applicant must provide an explanation as to the manner in which the funds are held in escrow. This explanation shall be attached hereto as Exhibit _______ (insert exhibit number). (Note: The attached exhibit must be conspicuously labeled as an exhibit. It shall be deemed incorporated into Part 4.C as if set forth fully herein.)

4. Read the statements below and select the applicable statement by checking the space next to it (check only one):

________

An executed copy of the Non-Participating Manufacturer's Escrow Agreement is attached hereto as Exhibit ________ (insert exhibit number). (Note: The attached exhibit must be conspicuously labeled as an exhibit. It shall be deemed incorporated into Part 4.C as if set forth fully herein.)

________

In the alternative, the Tobacco Product Manufacturer, identified in Part 2, hereby swears its Escrow Agreement, in the form attached to the Certification signed on ________________ (enter date Certification was signed by month/day/year) and submitted pursuant to A.R.S. § 44-7111, which was deemed complete and accepted by the Attorney General, is still in full force and effect without amendment or modification. (When choosing this option, the Tobacco Product Manufacturer need not attach as an exhibit a copy of its Escrow Agreement.)

D. Escrow Deposit/Withdrawal History for Arizona

Read the statements below and select the applicable statement by checking the space next to it (check only one):

________

The Applicant hereby attaches as Exhibit ________ (insert exhibit number) copies of records of the financial institution establishing: (i) the amount the Non-Participating Manufacturer deposited in the fund
for Units Sold in Arizona during 2021 as well as the date and amount of each deposit; (ii) the amount and date of any withdrawal or transfer of funds the Non-Participating Manufacturer made at any time from the fund into which it ever made escrow deposits pursuant to A.R.S. § 44-7101; and (iii) the total amount of funds held in escrow for the benefit of the State of Arizona. (Note: The attached exhibit must be conspicuously labeled as an exhibit. It shall be deemed incorporated into Part 4.D as if set forth fully herein.)

________

The Applicant hereby certifies that it has not deposited, nor has it been required to deposit during any year, any money into a Qualified Escrow Fund for the benefit of the State of Arizona pursuant to A.R.S. § 447101 on account of Units Sold in Arizona.

Note: All withdrawals must comply with A.R.S. § 44-7101(3)(b)(2) and verification of compliance must be provided.

E. Bond Requirement – check one of the below options

1. _______

The Applicant hereby attaches an original Surety Bond form as Exhibit _____ (insert exhibit number).

2. ________

(Not an option if the form has changed - please check online): In the alternative, the Applicant identified in Part 2 affirms that the information contained in the NPM Surety Bond form dated ________________________, as submitted to the Arizona Attorney General’s Office, is still true and accurate in all respects. The Applicant also affirms that the NPM Bond identified in the NPM Surety Bond form is currently in effect and will remain in effect until such time as a new and approved bond is executed.

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F. Immunity Waivers – check one of the options below

1. _______

If the Applicant is owned by a Native American tribe, complete the NPM Waiver of Sovereign Immunity by Native American Tribe form located at https://www.azag.gov/consumer/tobacco/forms
and attach it hereto as Exhibit ____ (insert exhibit number).

_______

(Not an option if the form has changed - please check online): In the alternative, the Tobacco Product Manufacturer, identified in Part 2, hereby swears its NPM Waiver of Sovereign Immunity by Native American Tribe form attached to the Certification signed on ________________ (enter date Certification was signed by month/day/year) and submitted pursuant to A.R.S. § 44-7111, which was deemed complete and accepted by the Attorney General, is still in full force and effect without amendment or modification. (When choosing this option, the Tobacco Product Manufacturer need not attach as an exhibit a copy of its NPM Waiver of Sovereign Immunity by Native American Tribe form).

2. _______

If Applicant is a Tobacco Product Manufacturer owned by a government entity other than a Native American Tribe located in the United States, complete the Government-Owned NPM Waiver of Sovereign Immunity form located at https://www.azag.gov/consumer/tobacco/forms and attach it hereto as Exhibit _____ (insert exhibit number).

_______

(Not an option if the form has changed - please check online): In the alternative, the Tobacco Product Manufacturer, identified in Part 2, hereby swears its Government-Owned NPM Waiver of Sovereign Immunity form attached to the Certification signed on ________________ (enter date Certification was signed by month/day/year) and submitted pursuant to A.R.S. § 44-7111, which was deemed complete and accepted by the Attorney General, is still in full force and effect without amendment or modification. (When choosing this option, the Tobacco Product Manufacturer need not attach as an exhibit a copy of its Government-Owned NPM Waiver of Sovereign Immunity form).

3. _______

If Questions 1 and 2 do not apply, please complete the NPM Standard Waiver of Sovereign Immunity form located at https://www.azag.gov/consumer/tobacco/forms and attach it hereto as Exhibit _____ (insert exhibit number).

_______

(Not an option if the form has changed - please check online): In the alternative, the Tobacco Product Manufacturer, identified in Part 2, hereby swears its NPM Standard Waiver of Sovereign Immunity form attached to the Certification signed on ________________ (enter date Certification was signed by month/day/year) and submitted pursuant to A.R.S. § 44-7111, which was deemed complete and accepted by the Attorney General, is still in full force and effect without amendment or modification. (When choosing this option, the Tobacco Product Manufacturer need not attach as an exhibit a copy of its NPM Standard Waiver of Sovereign Immunity form).

Part 5:

Non-Participating Manufacturer Certification – Status as a Tobacco Product Manufacturer

To respond to the questions in Part 5, please re-print the questions below and provide answers to each. This document shall be attached hereto as Exhibit ________ (insert exhibit number). (Note: The attached exhibit must be conspicuously labeled as an exhibit. That exhibit and accompanying attachments shall be deemed incorporated into Part 5 as if set forth fully herein.)

All materials provided in support of the Applicant's responses to Part 5 must be referenced in the Applicant's responses as
Attachment 1, 2, 3, etc., and conspicuously labeled as such. Any such documents, if properly referenced and attached, will be deemed incorporated into the Applicant’s applicable Part 5 responses as if set forth fully therein. All supporting materials that are written in a language other than English must be translated into English in order to be considered. In the event the Applicant is unable or unwilling to respond to a particular question in Part 5, the Applicant shall state this and provide the reasoning therefor. In the event the Applicant simply does not respond to a question or a sub-part thereof, the Certification will be rejected as incomplete.

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State Of Arizona Tobacco Product Manufacturer Arizona