Quarterly Manufacturer Certification Form 2026

Tobacco manufacturers can use this form to submit their quarterly certification to the Tobacco Enforcement Section. Provide the required company and product information, attach supporting files, and sign to certify.

"*" indicates required fields

Please comply with certification checklist and instructions and upload with documentation.

Failure to provide all necessary information will result in the rejection of your certification.

PART I: Tobacco Product Manufacturer Identification

Company Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone Number*

Factory Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Factory Manager Name*

First Last

Factory Telephone Number*

Do you have additional Factories?

Yes

Factory Address – 2

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Factory Manager Name -2

First Last

Factory Telephone Number – 2

Name of Designated Contact*

First Last

Email Address Designated to Accept All Official Communication*

Name of Legal Counsel for cc (optional)

First Last

Legal Counsel Email Address

Company Website Address- enter a valid website URL

Manufacturer’s Federal Taxpayer ID#*

Name of Importer*

Importer’s Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Importer’s Federal Taxpayer ID#*

US Customs ID#*

Do you have multiple Importers?

Yes

Name of Importer -2

Importer’s Address -2

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Importer’s Federal Taxpayer ID# -2

US Customs ID# -2

Do you have an additional Importer?

Yes

Name of Importer -3

Importer’s Address -3

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Importer’s Federal Taxpayer ID# -3

US Customs ID# -3

If more than, three importers please fill out additional attachment.

Verify that all currently held information is correct and has not changed or expired.

Yes

Please attach updated documentation and complete all sections of this form

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Max. file size: 256 MB.

This form is (Check One):*

First Quarter

Second Quarter

Third Quarter

Fourth Quarter

PART II: General Questions

1. Are you the actual manufacturer (i.e. fabricator) of the brands listed in this certification?*

Yes

Both

Explain your reason for certifying*

2. Are you the Trademark Owner of the brands listed in this certification?*

Yes

Both

Owner Name*

Provide the name and contact information of the owner, attach a copy of the live trademark from the USPTO website and a copy of any agreement that defines trademark rights and/or control over the manufacturing of the cigarettes (such as an exclusive manufacturing agreement) and attach an executed copy of such agreement.

If ownership or rights to trademark or brand have changed, please explain and attach any applicable trademark(s) and/or licensing agreement(s).

First Last

Owner Contact Information*

Live Trademark*

A copy of your full live trademark(s) from the last 30 days from the USPTO website. Ensure all fields of the trademark are expanded, displaying all details.

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Max. file size: 256 MB.

Executed Copy of Trademark Agreement*

Attach an executed copy of above trademark agreement.

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Max. file size: 256 MB.

3. Do you own, license, market, or hold rights to market in the United States, by way of a trademark, licensing agreement or other authority, any brands or brand styles of cigarettes or roll-your-own tobacco which you are not seeking to certify at this time?*

Yes

List the brands and brand styles you own, license, market, or hold rights to market which you are not seeking to certify in Pennsylvania. If you have certified or are seeking to certify those brands in other states, please identify the other states and status of those certifications (e.g. “certified” or “seeking to certify”).*

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Max. file size: 256 MB.

4. Have you ever had an enforcement action taken against you (in any state including PA) that you have not previously disclosed to this Office. If you have previously supplied information for these types of actions, click "disclosed prior" and add year of disclosure.*

Yes

Disclosed Prior

List the state(s) involved, date and a detailed explanation*

Additional Files*

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Max. file size: 256 MB.

Please list year of disclosure*

5. Have you ever been denied Directory Listing in any U.S. jurisdiction that you have not previously disclosed to this Office? If you have previously supplied information for these types of actions, click "disclosed prior" and add year of disclosure.*

Yes

Disclosed Prior

Please list year of disclosure*

List the state(s) involved, date and a detailed explanation*

If you have previously supplied information for these types of actions, please list year of disclosure.*

Additional Denied Directory Files

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Max. file size: 256 MB.

6. Are the responsible parties current with their monthly report filings to the PA Department of Revenue in accordance with the federal Prevent All Cigarette Trafficking (PACT) Act/Jenkins Act 15 U.S.C § 375 – 378?*

Yes

Explain why the responsible parties are not current with their monthly PACT act report filings to the PA Department of Revenue*

7. Are any of your brand styles, contained in this certification, currently under review or been issued a Non-Substantial Equivalence Order by the FDA within the past two (2) years?*

Yes

Provide the FDA documentation regarding the review/ recall of the brand or brand style and a detailed explanation.*

Please provide the signed and notarized FDA affidavit located below stating all certifying brands/styles are current and in compliance with FDA rules and regulations.

View/Download Notarized Affidavit

For any newly added brand style(s) please provide documentation to establish the style(s) in compliance with the Family Smoking Prevention and Tobacco Control Act, and therefore able to be sold legally in the United States.

Should a brand style be determined to be Non-Substantially Equivalent throughout the course of the year, you are required to provide information as soon as it is made available to ensure that products on the Directory remain legal for sale.

Upload FDA documentation files*

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Max. file size: 256 MB.

8. Have your manufacturing facilities changed locations within the last certification year? If so, please include the location where the brand style is manufactured on the Required Brand list template (updated 2026).*

Yes

Provide photos and a diagram of the new manufacturing facility*

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Max. file size: 256 MB.

9. Attach a list of all officers, owners, board members, or partners of your company, including their name, title, address, telephone number, and email address, and please indicate whether any such person is authorized to legally bind the company by signing or submitting a certification.*

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Max. file size: 256 MB.

10. Do you have any parent, subsidiary, sister, related, associated, or other affiliated entities?*

An “affiliate” is defined as a person who, directly or indirectly, owns or controls, is owned or controlled by, or is under common ownership or control with, another person. For purposes of the definition of “affiliate,” the terms “own,” “owned,” and “ownership” mean ownership of an equity interest, or equivalent thereof, of 10% or more.

Yes

List all such entities, their relationship and whether they manufacture, sell, distribute, ship, or report tobacco products for sale in PA. Attach additional sheets if necessary.*

Company Name and Address

Contact Person and Telephone Number

Does this Company Sell, Distribute, Ship, or Report Tobacco Products for Sale in PA?

Upload Files

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Max. file size: 256 MB.

11 . CSA/Distributors – Existing Non-Participating Manufacturers. Upload a list of all distributors used during the applicable certification year.*

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Max. file size: 256 MB.

PART III. First Quarter Certifications

(Unless there have been changes to previously submitted information or previously submitted documentation has expired)

General Questions to the Manufacture (attach additional sheets if necessary)

12 . Do you have a new qualified escrow account/fund with a qualified escrow agent subject to the current OAG qualified escrow agreement?*

Yes

Upload a copy of a new qualified agreement which has been approved by this office.*

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Max. file size: 256 MB.

13. Do you have the signed Health Warning Rotation Plan compliance affidavit – template provided in the sidebar.*

Yes

Upload the signed Health Warning Rotation Plan compliance affidavit – template provided in the sidebar.*

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Max. file size: 256 MB.

Explain why an FTC approval letter it is not available*

14. Do you have a copy of the U.S. Centers for Disease Control (CDC) ingredient listing compliance letter for the current year for all of the brands listed in this certification.*

Yes

Attach a copy of the U.S. Centers for Disease Control (CDC) ingredient listing compliance letter for the current year for all of the brands listed in this certification.*

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Max. file size: 256 MB.

Explain why CDC letter is not available.*

15. Attach a copy of the PA Department of Revenue’s Cigarette Fire Safe Manufacturer Certificate and corresponding laboratory Ignition Propensity individual test burn results and Certifications for the Ignition Strength of Cigarettes for each brand style.*

Test results expire three years after the date of the test regardless of the expiration date of the applicable fire safe certificate. For tests that will become three years old within three months of submission of this certification, manufacturers are advised that submitting updated tests may help expedite review and processing of the certification.

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Max. file size: 256 MB.

16. Do you have a copy of any Pennsylvania Tobacco Products Licenses*

Yes

Attach a copy of any Pennsylvania Tobacco Products Licenses*

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Max. file size: 256 MB.

17. Is a copy of your currently qualified escrow agreement on file with our office?*

Yes

Upload your escrow agreement*

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Max. file size: 256 MB.

18. Provide an electronic color copy of every brand style or promotional packaging. Include views of each side of the packaging with UPC clearly visible.*

Please be sure the packaging provided is clear of any proprietary information as it will be displayed to the public on the Pennsylvania Tobacco Product Directory of Approved Brands.

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Max. file size: 256 MB.

19. Attach copy of TTB Manufacturer of Tobacco Products permit and, if applicable, TTB Tobacco Importer permits for all Importers.*

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Max. file size: 256 MB.

PART IV: All Quarters

Section A. Brand Styles*

Use this space to upload the Required Brand List. Use the Brand List template provided (downloadable Excel File in the sidebar), indicate all styles to add/remove/remain. Please note changes have been made to the 2026 Brand List Template.

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Max. file size: 256 MB.

Section B. Brand Transfers

If, through a purchase or transfer of a brand, brand style or formula, a brand style has ever been owned, marketed or manufactured by another manufacturer, upload the required Brand Transfers Template. Further documentation may be requested to verify sales and purchase details.

Use this space to upload the required Brand Transfers Template provided (downloadable Excel File in the sidebar).

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Max. file size: 256 MB.

No Files to Upload

No Additional Files to Upload

Section C. Quarterly Shipment History*

Using the required Shipment History Template provided, identify every shipment of unstamped cigarettes or non-SET-paid RYO tobacco manufactured by your company during the prior quarter.

List all states and U.S. territories to which you (the manufacturer), your importer, or any other entity shipped unstamped cigarettes or RYO tobacco belonging to your brand families during the prior quarter. You are responsible for all shipments made by any importer/s.

If you were not the only manufacturer of any of your brand families or styles that shipped into any state or U.S. territory during the prior quarter, upload the required Shipment History Template provided (downloadable Excel File in the sidebar).

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Max. file size: 256 MB.

Section D. Quarterly Units Sold History*

For the prior quarter please certify how many units were sold into Pennsylvania, as defined by 35 P.S. § 5673 and 35 P.S. § 5702.102. You are responsible for all units sold in PA.

Using the required Units Sold Template provided (downloadable Excel File in the sidebar), identify all units sold within the Commonwealth of Pennsylvania during the prior quarter belonging to a brand family that belongs to the above named tobacco product manufacturer.

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Max. file size: 256 MB.

PART V: First Quarter Residency Status

(Unless there have been changes to previously submitted information or previously submitted documentation has expired)

Manufacturer Residency Status

The undersigned certifies that the above-named Tobacco Product Manufacturer (check one):

is a resident of the Commonwealth of Pennsylvania

has appointed the resident agent identified below for service of process in the Commonwealth of Pennsylvania

Resident Agent/Company Name*

Date of Appointment*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone Number*

Email Address*

Importer(s) Residency Status

If the above-named Tobacco Product Manufacturer’s cigarettes/RYO are manufactured outside of the United States, the undersigned certifies that the importer(s) of such cigarettes/RYO has executed a declaration prescribed by the Attorney General accepting joint and several liability as required by 35 P.S. §5702.304 and (1) is a resident of the Commonwealth of Pennsylvania or (2) has appointed the resident agent(s) identified in the letters attached below for service of process in the Commonwealth of Pennsylvania.

All of the above-named Tobacco Product Manufacturer’s cigarettes/RYO are manufactured within the United States.

At least some of the above-named Tobacco Product Manufacturer’s cigarettes/RYO that are sold in the United States are manufactured outside of the United States.

Upload Manufacturer Resident Agent Letter, Importer(s) Resident Agent Letter(s) and Importer Declaration form(s).

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Max. file size: 256 MB.

Part VI: All Quarters – Escrow Account Information

Escrow Account Information

If changed, attach a fully executed copy of the current Qualified Escrow Agreement including any amendments or attachments. A copy of the Pennsylvania Model Escrow Agreement is available on our website.

Drop files here or

Max. file size: 256 MB.

Once an escrow agreement has been approved you cannot change it without prior approval of this Office. This includes a change in financial institution, including through a buyout or merger. This Office reserves the right to require a new escrow agreement. We also, reserve the right to reject any revisions which have not been approved in advance. Please verify that your financial institution is submitting copies of your escrow statements to our office.

Section V N/A
N/A

Section A. Qualified Escrow Fund – Financial Institution

Name of Institution*

Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Authorized Representative Name/Title*

Phone*

Email*

Escrow Account Number*

Pennsylvania Sub-Account Number (if applicable)

Date of Executed Escrow Agreement*

Section B. Escrow Fund Deposit/Withdrawal History for Pennsylvania

Deposit/Withdraw History*
Provide the escrow deposit/withdrawal history. Attach proof of the current balance and updated account ledger of the escrow account as provided by the escrow agent and proof of the date of the most recent deposit. Failure to comply may result in denial of your certification.
Date
Deposit
Withdrawal
Balance

Upload Current Proof of Deposit and complete Deposit/Withdraw History*

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Max. file size: 256 MB.

Section C. Surety Bond Status

Calculating the Required Bond Amount
A bond required pursuant to 35 P.S. §5702.313 must provide a bond amount of at least the highest amount of escrow owed by the above-named Tobacco Product Manufacturer for any four consecutive calendar quarters over the past 12 calendar quarters. If the required bond amount increases before the next annual certification is due, the bond amount must be adjusted as required by 35 P.S. §5702.313 with notice to the Attorney General.

Surety Bond Information

Bond Amount:*

Effective Date:*
MM slash DD slash YYYY

Bond Number:*

Surety Name:*

The undersigned certifies that the above-named Tobacco Product Manufacturer has posted a bond for the sole benefit of the Commonwealth in the amount required by 35 P.S. §5702.313 using the bond form prescribed by the Attorney General.

Upload Executed NPM Bond Form*

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Max. file size: 256 MB.

Section D. Required Certification Checklist Form TES-016*
Upload Additional Documents

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Max. file size: 256 MB.

PART VII: Execution by Corporate Officer or Director

I understand that any violation of the requirements of the Tobacco Product Manufacturer Directory Act or of the Tobacco Settlement Agreement Act is a basis for removal of the manufacturer’s brand families from the Commonwealth’s Directory of Approved Brands.

I agree that all packaging images submitted with this certification are free of proprietary and confidential information and may be publicly posted on the Pennsylvania Tobacco Product Directory website.

I hereby certify, under penalty of perjury, that the Tobacco Product Manufacturer identified in Part I is a Non-Participating Manufacturer in full compliance with the Tobacco Settlement Agreement Act, is a resident of the Commonwealth, or, if not a resident has appointed a registered agent for service of process, has established and continuously maintains a qualified escrow fund, and has executed the current qualified escrow agreement approved by the Attorney General.

I hereby certify under penalty of perjury that the brand families submitted for inclusion on the Pennsylvania Tobacco Product Directory of Approved Brands are legal to sell in the United States under the Family Smoking Prevention and Tobacco Control Act and all regulations promulgated thereunder and therefore have been approved/certified by the FDA and/or are currently under review by the FDA. If a brand family style has been issued a Non-Substantially Equivalent Order or any other determination by the FDA making the product no longer able to be sold in the US, we will notify the Office of Attorney General immediately.

I hereby certify under penalty of perjury that I will continually update the information and documentation provided in this certification if it changes at any time, to ensure the products contained on the Pennsylvania Tobacco Product Directory of Approved Brands are able to be legally sold.

I hereby certify and declare under penalty of perjury that all of the statements and information contained in the certification, including but not limited to any accompanying statements or attachments herewith, are true, correct and complete and that I am a person authorized to bind the Tobacco Product Manufacturer making this certification either under the laws of the Commonwealth of Pennsylvania or of the jurisdiction where the manufacturer resides or is organized.

I affirm under penalty of perjury that the brand families included in this certification are the cigarettes of the undersigned TPM, who takes responsibility for purposes of calculating payment of escrow into a qualified escrow account as required under the TSAA.

Authorized Signature*

Print Name*

Title*

Signatory’s Email address*

Signatory’s Telephone number*

Attorney General Sunday

Office of Public Engagement

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Quarterly Manufacturer Certification Form 2026

Tobacco Enforcement Section

PART I: Tobacco Product Manufacturer Identification

PART II: General Questions

PART III. First Quarter Certifications

PART IV: All Quarters

PART V: First Quarter Residency Status

Part VI: All Quarters – Escrow Account Information

Section A. Qualified Escrow Fund – Financial Institution

Section B. Escrow Fund Deposit/Withdrawal History for Pennsylvania

Section C. Surety Bond Status

PART VII: Execution by Corporate Officer or Director