2025 TEST – Participating Manufacturer Certification Form _copy

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

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 that the style(s) are compliant with the Family Smoking Prevention and Tobacco Control Act, and all regulations promulgated thereunder, and therefore are able to be sold legally in the United States.

Should a brand style be determined to be Non-Substantially Equivalent or otherwise recalled by the FDA throughout the course of the year, you are required to provide information as soon as it is made available to ensure that products that are not legal to be sold do not remain on the Directory.

I understand that any violation of the requirements of the Tobacco Product Manufacturer Directory Act or 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 Participating Manufacturer under the Master Settlement Agreement who is compliant with their financial obligations as set forth in the MSA.

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 under the MSA for the relevant year in volume and share determined under the MSA.