2025- -TEST Non-Participating Manufacturer Certification Form _copy

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.

Using the Required Yearly Shipment History template provided, identify every shipment of unstamped cigarettes or non-SET-paid RYO tobacco manufactured by your company during the prior year.

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 year. 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 year, on an attachment provide the name and address of every other manufacturer and the dates of manufacturer by each manufacturer for each brand family or style.

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 during the year, 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.