¢ 1s directory {rev. & tax. code,§ 30165.1) ,ei djus-tob 1 (rev 06/2012) certification for...

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REPEAL STATE OF CALIFORNIA DEPARTMENT OF JUSTICE

PAGE 1 of 12

JUS-TOB 1 (Rev. 06/2012)

CERTIFICATION FOR LISTING ON CALIFORNIA

DIRECTORY {REV. & TAX. CODE,§ 30165.1) r��

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,ei

·\ . '" ·� -::' DATE OF APPLICATION: D INITIAL D SUPPLEMENTAL "--0'�'\

PLEASE\N(PE OR FILL OUT IN PERMANENT BLUE INK.

PART I: \qENERAL BUSINESS AND OWNERSHIP INFORMATION

1. APPLICA��OBACCO PRODUCT MANUFACTURER IDENTIFICATION.

APPLICANT:.\--4,-------------------------�-------.--------

STREET ADORE�£:

\-------------------------CITY: --�\ __________ STATE:,,,___

COUNTRY:

MAILING ADDRESS IF DIF}'FiRENT FROM ABOVE:

ADDRESS:

CITY: STATE: ZIP CODE:

COUNTRY: ---------+-------------+-------------------

PHONE NUMBER: -------�--------

E -MA IL ADDRESS: _________,,,_______ _

NAMEfTITLE OF PERSON COMPLETING CER�ATION: __ _____________________ _

MANUFACTURING PLANT(S) NAME AND ADORES\ DIFFER

NAME:

ADDRESS:

CITY: ZIP CODE:

COUNTRY: -----------;F--------"r-----------------------

MANUFACTURING PLANT PHONE NUMB5R MANUFACTURING PLANT FACSIMILE (FAX) NUMBER:

NAMEfTITLE/PHONE NUMBER 7SON AT PLANT IF DIFFERENT FR

(ATTACH ADDITIONAL SHE T(S), IF NECESSARY, TO PROVIDE COMPLETE RES ONSE.)PLEASE ATTACH A PHO OGRAPH OR DIAGRAM OF YOUR MANUFACTURING FA ILITY AND INDICATE ON THE PHOTOGRAPH OR DIAGRAM WHERE THEI QUIPMENT AND FACILITIES FOR MANUFACTURING (i.e., BRICATING) THE CIGARETTES, IF ANY, ARE LOCATED. /

2. THE UNDERSIGNEfoCERTIFIES THAT AS OF THE PATE OF THIS CERTIFICATION, THE BOVE-MENTIONED APPLICANT IS: (INITIAL ONE) / ___ AP RTICIPATING MEMBER ("PM"). (IF APPLICANT IS A PM, IT MAY GO DIRECTL TO QUESTION SEVEN OF PART 1.)

A NON-PARTICIPATING TOBACCO PRODUCT MANUFACTURER ("NPM") IN FULL COM LIANCE WITH CALIFORNIA'S RESERVE FUND STATUTE (HEAL TH & SAFETY CODE SECTIONS 104555-104557) AND IMPLEMEN NG REGULATIONS, INCLUDING HAVING MADE ALL REQUIRED DEPOSITS INTO A QUALIFIED ESCROW FUND FOR ALL ARS BEGINNING WITH YEAR 2000 SALES.

-.'---

PPLICANT IS THE MANUFACTURER (i.e., FABRICATOR) OF THE BRANDS LISTED IN THIS CERTIFIC TION WHICH ARE INTENDED TO BE SOLD IN THE UNITED STATES, INCLUDING CIGARETTES INTENDED TO BE SOLD IN THE UNITED S ATES THROUGH AN IMPORTER.

l YES C NO

of 12

JUS-TOB 1 (Rev 06/2012)


DIRECTORY (REV. & TAX. CODE, § 301 65."l )

B.

ST ATE OF CALIFORNIA DEPARTMENT OF JUSTICE

UNITS SOLD INA. BRANDFAMILY(INDICATEWIT71ANASTERISK(")THOSEBRANDSTHATWILLNOT/BESOLDINAPPLICATION Cco. ED(INCLUDEPRECEDING \,:METFEAACTDUDRREERSSOIFNBFoRARNMDASTILolSNT)

/YEAR) CALENDAR YEAR

/! /' S

/i{

]

S /

S/

// S

"S/ ]

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE

PAGE 3 of 12

JUS-TOB 1 (Rev 06/2012)


DIRECTORY (REV. & TAX. CODE, § 30165.1 )

1. BRAND FAMILY IDENTIFICATION, CONT'D. (PMs COMPLETE COLUMN A, NPMs COMPLETE COLUMN A THROUGH C.)

A. BRAND FAMILY (INDICATE WITH AN ASTERISK (") B. UNITS SOLD IN C. MANUFACTURER OF BRANDS LISTED (INCLUDE

'I,HOSE BRANDS THAT WILL NOT BE SOLD IN APPLi6ATION PRECEDING COMPLETE ADDRESS INFORMATION)

Y%m CALENDAR YEAR

S /"%

ATT ACH ITIONAL SHEET(S), AS NECESSARY, TO PROV;DE A COMPLETE RESPONSE.

ATTACH SOFTHEACTUALPACKAGINGANDLABELINGOFCARTONSANDPACKSFOREACH STYLE OF

CIGARETTES T APPLICANT INTENDS TO SELL IN CALIFORNIA. ALSO SUBMIT, ON CD OR DVD, A PHOTOGRAPH IN

ADOBE 8-0 (.PDF ARE, OF THE PACKAGING AND LABELING. FOR EACH BRAND FAMILY, A COPIE8 0F YOUR

WRITTEN nON OF COMPLIANCE WITH THE CALIFORNIA CIGARETTE FIRE SAFETY PROTECTION ACT.

WHICH YOU FILED THE STATE FIRE MARSHAL. (HEALTH & SAF. CODE, § 14951, SUBD. (a) Y, SUBMIT A COMPLETED

BRAND STYLE nON INFOR?AAnON FORM (JUS-TOB15) FOR EACH BRAND STY

2. TRADEMARK Ha ER(S). (IF APPLICANT IS A PM, IT MAY SKIP QUESTION 2 AN DIRECTLY TO DECLARATION,

ACKNOWLEDGEMENTAND NATUREPAGE12.)PROVIDETHENAME,ADDRESSAND ONE NUMBER OF THE

TRADEMARK HOLDER(S) OF H BRAND LISTED ABOVE.

///

BRAND X'X:.c=ARcTHSEoN PHYSICAL,=ADDRESS PHONE

/'X ,/

/

t! /

/XX /

', '% /'

,Xa

'% / S,

';X:,'.

!/" 'S %,

J, 7 '%,

a ! %

s

'IX S]

/ %, /

"S }a0,1 %

,/ S

ATTACH ADDITIONAL SHEET(S), AS xeces,ffqsy, TO PROVIDE A COMPLETE RE '\ONSE. PART Ill: ADDITIONAL BUSINESS FORMATION 1. ATTACHORGANIZATIONALDOC MENTS(SEEINSTRUCTIONSFORLISTOF UMENTS REQUIRED BY THIS

QUESTION). ooX 2. COMPANY OFFICERS AND

COMPLETE THE TABLE BY LISTING AtL COMPANY OFFICERS AND COMPANY OWNERS (ALL PE f30N S WITH AN EQUITY INTEREST OF

10% OR MORE IN APPLICANT COM . ATT ACH ADDITIONAL SHEET(S), AS NEEDED, TO PRO A CCMPLETE RESPONSE.

€ PRESIDENT0,-'6qprxepOvicepses 0 PARTNER € TREASURER0 PARTNER1 CHECK

OTHER TITLE APPROPRIATE OTHER ,." OTHER @oTHs:Rcpt=rqsy0 pqs"i'%,..

"'=,

i

(first, mid last) 2 FULL NAME

/ S 3 STREET ADDRESS S

li

TELEPHONE # !/

FACSIMILE #

5 DATE & PLACE OF BIRTH

4

6 E-MAIL ADDRESS


PAGE 4 of 12

JUS-TOB 1 (Rev 06/2012)



3. AFFILIATES INFORMATION (SEE INSTRUCTIONS FOR FURTHER INFORMATION).

ATTACH ADDITIONAL SHEET(S), AS NECESSARY, TO PROVIDE A COMPLETE RESPONSE.

TYPE OFBRAND FAMILY AFFILIATE: NAME

BUSINESS y AFFILIATE.STREE%RESS S /

S / .,,//8

4. APPLICANT

PLEASE INDICATE WH ITHER YES OR NO AFTER THE ST ATEMENT.

APPLICANT S (' YES (' NO

APPLICANT MADE ES OW DEPOSITS PURSUANT TO CALIFORNIA'S RE (' YES (' NO (HEALTH&SAFETYCOD SECTIONS104555-104557)INTHEPRECEDI

ONE OR MORE OF THE BRAND (' YES (' NO

d APPLICANTMADEESCROWDEPOS INTHEPRECEDING DARYEARPURSUANTTOCALIFORNIA'S

RESERVE FUND STATUTE FOR ONE MORE OF THE B D FAMILIES LISTED IN THIS CERTIFICATION: c--'s r' "o

THERE HAS BEEN A CHANGE IN MANUFAC R (i. ., FABRICATOR) FOR ONE OR MORE OF THE BRAND gYES('aNO FAMILIES LISTED IN THIS CERTIFICATION N E PAST TWO CALENDAR YEARS:

APPLICANT ADVERTISES OR SELLS CI THE INTERNET OR IN CAT ALOGS AND USES THE (' YES (' NO MAIL OR OTHER DELIVERY SERVICE TO D CI S TO CALIFORNIA CONSUMERS:

APPLICANTFAILEDTOTIMELYCOMPLY THERESE FUNDSTATUTEPRIORTOTHE (' YES (' NO ESTABLISHMENTOFTHEDIRECTORY RATANYTIMETH -

APPLICANT OR ONE OF ITS B FICATION WAS PREVIOUSLY DENIED (' YES (' NO LISTING ON ANY ST ATE'S TOBA FROM THE DIRECTORY:

APPLICANT IS ENJOINED 0 (' YES (' NO ORDER, ST ATE OR FEDE

FAMILY ERLY FAMILY TO No3. ABRAND FO SOLDBYAPPLICANTORABRAND THAT ICANTINTENDED (- YES ('SELL IS ENJOINED SALE BY ANY ST ATE COURT, ST ATE AGENCY OR A FED COURT:

A ST ATE OR FE GAGEDIN AN (' YES (7 NO UNFAIR BUSIN 0 PRODUCTS:

APPLICANT OLDMORETHAN1,600,OOOCIGARETTESINCALIFORNIADURINGANYQUARTER AFTER (' YES (' NO JANUARY ,2000:

APPLI FAILED TO TIMELY FILE ANY COMPLETED FORM OR DOCUMENT REQUIRED BY THE RESERVE ( YES (' NO STATUTE OR REVENUE AND TAXATION CODE SECTION 30165.1 AND IMPLEMENTING REGULATIONS:


PAGE 5 of 12

JUS-TOB 1 (Rev 06/2012)



PART IV: MARKETING AND DISTRIBUTION INFORMATION

TOBACCO PRODUCTS RECLASSIFIED AS CIGARETTE OR RYO TOBACCO.

LIST ALL TOBACCO PRODUCTS SOLD BY APPLICANT THAT HAVE BEEN RECLASSIFIED WITHIN THE LAST TWO YEARS AS CIGARETT,ES

SOR AS ROLL-YOUR-OWN (RYOi TOBACCO BY A FEDERAL AGENCY. STATE OR LOCAL GOVERNMENT.

NAME OF FEDERAL, ST ATE OR

LOCAL GOVERNMENTAL ENTITYXBRANDNAME OF GOVERNMENT ENTITY'S STREET oarseQqssipia:i TOBACCO THAT RECLASSIFIED THE ADDRESS sec4ssipicqnox

PRODUCT THE TOBACCO PRODUCT AS A

CIGARETTE OR RYO TOBACCO 'S,

S //

S // S /

S /

S/

rx/

S /" /

/

ATTACHADDITIONALSHEET(S),ASNECESSARY, OPROVIDEACOMPLETEJ%ESPONSE

2. DISTRIBUTORS, WHOLESALERS AND RET

FOR EACH BRAND THAT APPLICANT INTENDS TO SELL IST THE NAM,e-AND ADDRESS OF EVERY CALIFORNIA DISTRIBUTOR, WHOLESALER, OR RET AILER WHICH PURCHASED OR DLED TEN/PERCENT OR MORE OF APPLICANT'S GROSS CIGARETTE SALES FOR THAT BRAND IN CALIFORNIA IN THE LAST CALENDAR

DISTRIBUTORS:

BRAND FAMILY DISTRIBUTOR / / "'%,, STREET ADDRESS PHONE NUMBER

/ ""%%S%% /"

// ""%%l%l

,/// S

/

/

/ "%1SI) ATTACH ADDITIONAL SHEET(S), AS,Al'ECESSARY, TO PROVIDE A COMPLETE RESPONSE.

t/

'/VHOLESALERS: /

BRAND FAMILY /' WHOLESALER PHONE NUMBER /' STREETADDRESS S

%

//" S

I/ S /

's

ATTACH ADDITIONAL SHEET(S), AS NECESSARY, TO PROVIDE A COMPLETE RESPONSE


PAGE 6 of 12 JUS-TOB 1 (Rev 06/2012)


DIRECTORY (REV. & TAX. CODE, § 30165.i)

RET AILERS:

BRAND FAMILY RET AILER STREET ADDRESS PHONE NUMBER

"'%%lll / "y

S / A3TTACHAADGDR1'\)EE,NANLTSsHWEEITTH(SP),AARSTNlcEIPCAETSISNAGRMYA,TNOUFPARcOTVUlDREEARsCO,SMEPELEINTSETRREUSCPTOIONNSSE).

PARTICIPATING BRAND FAl'mS PHONE NUMBER

MANUFACTURER STREET /ADDRESS

S '% /

/ ',, /

S, /

S /

,i'

,/ -/

/' /

/

,/' /

,/NATUREOFAGREEMENT(S): S'= ,//"

/ /'

/'

,/'

X=' S A4TTACHAADGDRITEIEOMNAENLTSSHEREETG(ASR),DAlSNGNEcCoEMSPS!AIARYN:,.TEOWPIRTOHVTIHDEEMASCAOM(SPELEETINNSTCOTNICSNES.)

BRAND FAMILY ' STREET ADDRESSNAME X

,,j S -. .1,//,] S

i/' S/ a/

/ '% /

/"

q-rrq!qooirioxqi SHEET(S), AS NECESSARY, TO PROVIDE A COMPLETE RESPONSE.


PAGE 7 of 12

JUS-TOB 1 (Rev 06/2012)



5. AGREEMENTS REGARDING COMPLIANCE WITH THE RESERVE FUND ST ATUTE. (SEE INSTRUCTIONS)

BRAND FAMILY NAME STREET ADDRESS

\\S1

S / 'Sy

S ,/'%l

/ /"S

/

PART V: MARKETING AND%,COMPLIANCE INFORMATION

:6seqc:;::#%":r:,(ffi:ffirme'eqxoqoosessor-merxqxurqcrusest: <ssicqrosiopmecicqsenes.ir OTHER THAN APPLICANT. INCLUDE ALL QOMPANY NAMES AND ADDRESSES USED BY THE MANUFACTURER(S) IN MAKING CIGARETTES FOR SALE IN THE UNITED STATES

BRAND FAMILY "%yMANUFACTURER (i.e., FABRlCATO.j9'j' STREET ADDRESS

X /'a'x /

S'%'1 //

]

} /

"'XX,a/,,=7]]"

!><

/a/, X-! S

ATTACH ADDITIONAL SHEET(S), AS NECESSA5<Y, TO PROVIDE A COMPL RESPONSE.

2. HEALTHWARNINGROTATIONPJ.-AN. FOREACHBRANDFAMILY,LISTTHEN9.MEANDADDRESSOFTHEENTITYWH FILED A CIGARETTE HEALTH WARNING ROT ATION PLAN WITH THE FEDERAL TRADE COM/IISSION BEFORE THE CIGARETTES WERE STRIBUTED INTO THE UNITED STATES.

BRAND ,i' NAME OF FILER " S STREETADDRESS

]/

/ S,/

/'

i/ S /"

S/" /

/

\\)

FOR EACH BRAND, ATT ACH THE FEDERAL TRADE COMMISSION'S WRITTEN APPROb AL OF APPLICANT'S ANNUAL CIGARETTE HEALTH WARNING ROT ATION PLAN ATT ACH ADDITION AL SHEET(S), AS NECESSARY, TO PROVIDE A COMPLETE RESPONSE.

https://ssicqrosiopmecicqsenes.ir


PAGE 8 of 12

JUS-TOB 1 (Rev 06/2012)


DIRECTORY (REV. & TAX. CODE, § 30165.1 ) 3. INGREDIENT REPORTING.

FOR EACH BRAND FAMILY, LIST THE NAME AND ADDRESS OF THE ENTITY WHICH SUBMITTED THE INGREDIENT REPORTING

NFORMATION TO THE u.s. SECRET ARY OF HEALTH AND HUMAN SERVICES AS REQUIRED BY THE FEDERAL CIGARETTE LABELING AND ADVERTISING ACT.

, BRAND SUBMITTER STREET ADDRESS

S S

S S

/ /-

/ ANNUAL INGREDIENI

ATTACH ADDITIONAL

REPORTII G I !(

SHEET(S), AS N

IIRED

ESSARY.

BY TH ( FEDERA L ::IGARETTE LABELING l ADVERTIS 'G

TO PROVIDE A COMPLETE RESPONSE. /

4. CIGARETTEPACKAGING.

FOREACHBRANDFAMILY,LISTTHENAME

'x DADDRESSOFTHEPERSON,COMPANY,OREN;TfTYTHATPLACEDTHECIGARETTESINTO

ACKAGES WITH THE u.s. SURGEON GENEF, 'S WARNINGS

BRAND / ./ STREET ADDRESSX PACK-"(GER /

X , /

X /-/S !

% / %s /'

S /-='

X ,/ X%a

/% J %

/' %

l,/"" XXX /

a. WEBSITES

b. PHYSICAL ADDRESS:

c. roy@!sqies FORTHEPREVIOUSYEARIINCALIFORNIA

]/i/

ATTACH ADDITIONAL SHEET(S), AS NECESSARY, TO PROVIDE A COMPLETE RESPONSE.

(ATT ACH COPIES OF THE JENKINS ACT REPORTS FILED WITH THE CALIFORNIA BOARD OF EQUALIZATION, AS SPECIFIED IN THE INSTRUCTIONS.)

IF APPLICANT IS A PM, IT MAY GO DIRECTLY TO DECLARATION ACKNOWLEDGMENT AND SIGNATURE ON PAGE 11.

ST ATE OF CALI FORNIA DEPARTMENT OF JUSTICE

PAGE 9 of 12 JUS-TOB 1 (Rev 06/2012)

CERTIFICATION FOR LISTING ON CALIFORNIA DIRECTORY (REV. & TAX. CODE. 6 30165.1

PART ENFORCEMENTAND DETERMINATIONS74STOVl:DoliSsCrLnO=:uU,Ro:OsF PRIORACTIONS AFFECTING

(a) THE NAME OF THE APPLICANT OR OTHER PERSON OR AFFILIATE WHICH HAS NOT SATISFIED ITS NPM RESER ND OBLIGATIONS (b) THE BRAND FAMILIES FOR WHICH THERE WAS A FAILURE TO COMPLY, AND (c) THE AMOUNTS OF ANY ESCROW DEPOSITS THAT ARE STILL OWED.

@YES,THEDETAILS OCCURANCE TOTHISCERTIFICATION @NOTAPPLICABLE OFEACH AREATTACHED


PAGE 10 of 12

JUS-TOB 1 (Rev 06/2012)



PARTVII: IMPORTEDCIGARETTES-DOCUMENTATION&VERIFICATION

1. u.s. CuSTOMS DOCuMENTS.

PYOFTHEIMPORTER'SCERTIFICATE(S)UNDERPENALTYOFPERJURYASREQUIREDB 19USC§1681A(C)(2)

INGTHEPRECISEFORMATOFWARNINGSANDTHEROTATIONPLANFORHEALTH ARNINGS.

A COP F THE TRADEMARK HOLDER'S CERTIFICATE(S) UNDER PENALTY OF PERJUR TIT HAS NOT

WITHDRA CONSENTTOIMPORTINTOTHEUNITEDSTATESASREQUIREDBY19 §1681A(C)(3)(A)ORACOPY

OFTHEIM RTER'SCERTIFICATE(S)UNDERPENALTYOFPERJURYTHATTHE EMARKOWNERHASNOT

WITHDRAWN ONSENTTOIMPORTINTOTHEUNITEDSTATESASREQUIREDBY USC§1681A(C)(3)(B).

2.

3.

PART Vlll: NPM APPLICANT CER ICATION

1. AGENTFORSERVICEOFPROCESS.

2.

3.

DATE / DEPOSIT BALANCE /! WITHDRAWALX

/ S /

S/

//

S A

ATTACH ADDITIONAL SHEET(S), A3 NECESSARY, TO PROVIDE A Co)MPLETE RESPONSE.

NOTE: THIS CERTIFICATION WILL NOT BE PROCESSED OR

CONSIDERED UNTIL ALL THE REQulRED DOCUMENTS ARE SUBMITTED.

S


JUS-TOB j (Rev 06/2012) PAGE 11 of 12

DECLARATION, ACKNOWLEDGMENT AND SIGNATURE

UNDER PENALTY OF CRIMINAL PROSECUTION UNDER THE LAWS OF CALIFORNIA, I DECLARE AND ACKNOWLEDGE THAT:

SIGNATURE:

MY COMMISSION EXPIRES ON:

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE JUS-TOB (Rev 06/20 2 PAGE 2 of 2

THIS CERTIFICATION MUST BE FILED WITH THE ATTORNEY GENERAL'S OFFICE:

MAILING ADDRESS: STREET ADDRESS:

FOR THE ST ATE OF CALIFORNIA

rosbcho LITIGATION AND ENFORCEMENT

P. 0. BOX%.944255

sacsauek.ro. CA 94244-2550

SECTION

OFFICE OF THE ATTORNEY GENE

FOR THE ST ATE OF CALIFORN

TOBACCO LITIGATION AND E ORCEMENT

1300 I STREET, SUITE 125

SACRAMENTO, CA 95814

SE CTION

/,, ',,

ST ATE OF CALIFORNIA DEPARTMENT OF JUSTICE JUS-TOB1

PAGE 1 of 4 (Rev 06/2012) CERTIFICATION FOR LISTING ON CALIFORNIA

DIRECTORY (REV. & TAX. CODE, § 30165.1)

Tobacco and Safety Code) are sold

n California, ete and file this form (JUS-

TOB1).

This certification is addition to the Nonparticipating Manufacturer ("NPM") Certification of Compla ce (JUS-TOB3) required by

California's Reserve nd Statute (Health and Safety Code sections 104555-104557) and imple ting regulations (California Code of Regulations, Title 11, a 999. 10-999.14).

Initial/Annual Certifications: Every t cco product manufacturer currently selli agarettes in California must file a certification (JUS-

TOB1) no later than April 30, 2004. April 30, 2004, tobacco product man cturers which intend to sell cigarettes in California shall

file a certtfication and qualify for listing e directory prior to any sales in ifornia. Tobacco product manufacturers listed on the directory must file this form on or before at30th each year.

Supplemental Certifications: In completing a plemental certification pplicant must check the "supplemental" box at the top of page

one, enter only the new or changed information, sign and date supplemental certificaUon form. A tobacco product manufacturer

shallfileasupplementalcertification(JUS-TOB1) laterthanthi ayspriortoanychangeinafabricatorforanybrandfamilyorany addition to or modification of its brand families by e angand ivering the supplemental certification to the Attorney General. In all

other circumstances in which information provided on e certifi aon becomes inaccurate, a supplemental certification must be filed within

thirty (30) days after the information becomes inaccurat

Office of the Attorney General Office of the Attorney General

for the State of California for the State of California

Tobacco Litigation & Enforcement Section T cco Litigation & Enforcement Section

P.0, Box 944255 I I Street, Suite 125

Sacramento, CA 94244-2550 Sa ento, CA 95814

Definitions:

(a) "Affiliate" means a person who rectly or indirectly owns or controls, is owned controlled by, or is under common ownership or

control with, another person, as d ned in subdivision (b) of section 104556 of the He and Safety Code.

(b) "Brand family" means all es of cigarettes sold under the same trademark and diff 'ated from one another be means of addiUonal

modifiers, including, but not li to, "menthol," and includes any brand name, alone or in junction with any other word, trademark

logo, symbol, motto, selling essage, recognizable pattern of colors, or any other indicia of uct identification identical or similar to, or

identifiable with, a pre a known brand of cigarettes.

(c) "Cigarette" has the e meaning as in subdivision (d) of section 104556 of the Health and S ty Code. (Roll-your-own "RYO"

tobacco is included in definition of cigarette under section 104556.)

(d) "Directory" m the listing of all tobacco product manufacturers that have provided current and a rate certifications conforming to

the requirements Revenue and Taxation Code section 30165.1 and all brand families that are listed in s certifications.

(e) "Distributor" the same meaning as in section 30011 of the Revenue and Taxation Code.

(g) "Nonparticipating manufacturer," or "NPM," means any tobacco product manufacturer that is not a participating manufacturer.

ST ATE OF CALIFORNIA DEP ARTMENT OF JUSTICE

JUS-TOBI PAGE 2 of 4

(Rev 06/2012) CERTIFICATION FOR LISTING ON CALIFORNIA

DIRECTORY (REV. & TAX. CODE, § 30165.i)

(h) "Participating

(i)

(j) "Qu

(k) "Rese 104555).

(I) "Tobacco

This certification a if

the original docume

All attachments to this

If any section of this certifi aon

Any person who makes an a material

matter is guilty of a misdem

Part I.

3-6. Health and Safety Code section 1 04556(1) mstances under which an entity is a tobacco product manufacturer.

Those circumstances are individually set out in qu . If applicant answered "no" to questions 3, 4, and 5, applicant must

provide an explanation for its assertion that it is a toba manufacturer in its response to question 6.

7. Applicants must obtain a cigarette and/or tobacco ucts manufacturer's license and attach a copy or such license(s). (Cal.

Code Regs., tit.l 1, ch.16, § 999.16, subd.(b)(2)(D).) All acipating manufacturers must also provide a copy of a valid federal permit

from the u.s. Treasury, Alcohol and Tobacco Tax and T e Bu u. (Cal.Code Regs., tit. 11, ch. 16, § 999.16, subd. (b)(2)(J.).)

Part II.

1. Brand Family Identification

Identify by brand family all of the cigarettes th rer tntends to sell in California, whether directly or through

any distributor, retailer, or similar intermed directory. Only the brands identified may be included in

the directory. A participating manufactu B isting a brand family, the participating manufacturer affirms

that the brand family is deemed to be its payments under the MSA for the relevant year. The

participating manufacturer shall updat addition to or modification of its brand families by

executing and delivering a suppleme

Attach samples of the actual pa style of cigarettes that applicant intends to sell in

California. Also submit, on CD the packaging and labeling. For each brand

family, attach copies of your Safety and Firefighter Protection Act, which

you filed with the State Fire ted JUS-TOB15, Cigarette Brand

Authenticaflon Information

A nonpadicipattng ma cturer (NPM) shall: (l) List all or its brand families and the number of units

sold in California duri lifornia during the preceding

calendar year that a e complete name and address of

every tobacco p calendar year. The NPM

shall update su angand delivering a

supplemental e brand family is deemed

to be its a

implementing regulations.


JUS-TOBI PAGE 3 of 4 (Rev 06/2012) CERTIFICATION FOR LISTING ON CALIFORNIA

DIRECTORY (REV. & TAX. CODE, § 30"165.1)

Part Ill. Additional Business and Ownership Information (NPM Applicants only)

1X Organizational tobeattached:document's Ifap%antisa: Attachtocertification: / Partner%rAssociationCurrentofarticles,orthecertificatetobefiledanycopy ifany, required by sta%nicipality

X, 1. Current copy of the corporate charter or certificate of corporate a or incorporation. This

copy must be executed by the appropriate state officer for the a ' which incorporated.

2. Extracts of stockholders' meetings, bylaws, directors' meetings or documents that list theCorporation

'S officers authorized to sign documents or otherwise act on behalf of corporation. The accuracy of the

copy must be certified by an appropriate officer of the a . . / . . . .. ."y Currentcopy of the businessdocument(s)filed with a state,countyor municipalitywhen such filing is

Limitedliabilitycompanyo>q%therrequired. The copy mustshowthat it WaSfiled with the appr4riate governmentagency. A limitedliabilitybusiness organization %,,

'%, company must provide an accurate copy of its operating ag(eement.

3. Affiliates

Identify any affiliate that also manufa r tobacco products in California by completing the

table on the application. For the pu , the term "own" means ownership of an equity

interest, or the equivalent thereof, of 10 nds and the affiliate in the first two columns. List the

type of business by writing in the third colu rer, "I" for importer, "D" for distributor, and "W" for

wholesaler.

Part IV. Marketing and Distribution ormation

3. Agreements with participating manufa

Identify every agreement between applicant and any ufacturer (PM) or affiliate of a PM which relates to the making,

importing, distribution, transportation, or sale of a brand the brand family and the name, address, and phone number of the PM

involved in any agreement. For each brand family, descri greement or arrangement with any PM or affiliate of a PM in the making,

impor?ng, distribution, transportation or sale of the brand fam , and provide the name and address of the PM(s), subsidiary(ies), affiliate(s)

or partner(s). A list of the participating manufacturers is ava on the NAAG website at http://www.naag.org. Attach a copy or any

written contract(s) and/or agreement(s).

4. Agreements regarding compliance with th

List every brand family that is the subject of an ag ance with the MSA and the name, address, and phone number

of the participating manufacturer involved in such py of any written contract(s) and/or agreement(s).

5. Agreements regarding compliance

List every brand family that is the subject of the NPM Reserve Fund Statute and the name,

address, and phone number of the person ctual arrangement and/or agreement concerning

compliance with the NPM Reserve Fund s) and/or agreement(s).

Part V. ManufactJ:ng andComplianceInformation 5. Internet or mail o,ffler sales

If applicant intends to set y cigarettes (including RYO tobacco) by mail order or through the interne ist and describe: (A) Any website

advertising the cigarett (B) the address from where the cigarettes will be shipped, (C) and the tota in California in the previous

year.

Attach copies of enkins Act Reports. If applicant is applying for listing on California's Directory for the first a , attach copies of a

reports, if any, wifh the California Board of Equalization to comply with the Jenkins Act (Chapter 1 0A of Title 5 of the u.s. Code,

section 375 e .) for sales in the preceding 12 months. If applicant has already been listed on California's di but is applying to list

other or n rand Families, attach copies o( the Annual Certification of Compliance (JUS-TOB3) and the Jenkins rts for sales of

the alrea listed brand families for the period of time reported in applicant's Annual Certification of Compliance.

http://www.naag.org

ST ATE OF CALIFORNIA DEPARTMENT OF JUSTICE JUS-TOBI PAGE 4 of 4 (Rev 06/2012) CERTIFICATION FOR LISTING ON CALIFORNIA

DIRECTORY (REV. & TAX. CODE, § 30165.1)

11,ch.

foreign NPM that has registered to do business in

a resident agent for service of process pursuant to against it concerning or arising out or the enforcement

section 30165.1 and implementing regulations, may be egistered Agent (JUS-TOB2). (Cal. Code Regs., tit. 11, ch.

¢ 1s directory {rev. & tax. code,§ 30165.1) ,ei djus-tob 1 (rev 06/2012) certification for...

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